Gina Henderson, my editor at Clinical Psychiatry News, recently asked me an interesting question. She wanted to know what I believe the five most important issues are for psychiatry today. My first thought was that I am the wrong person to ask – aside from what comes through on my Twitter feed and the Maryland Psychiatric Society’s listserv, I have my own areas of interest and don’t know that I’m the best measure for the pulse of today’s psychiatric issues.
I imagine that different psychiatrists would respond with different answers. If I were to guess – and I haven’t verified this – I think my co-columnist, Anne Hanson, might suggest that the single most important issue for psychiatry is new legislation related to physician-assisted suicide and how that will be applied to psychiatric patients with reportedly intractable illnesses. Steve Daviss, who also writes for our Shrink Rap News column, has had an interest in parity legislation, adequacy of insurance networks, and the application of information technology to psychiatry, and he might say those are our pressing issues. My own interest has been in involuntary treatment, its impact on patients, and if there are ways we might avoid this or do it better.
I wonder if I am missing some new breakthrough now that patients are getting genetic testing to guide their treatment with results that befuddle me.
Using the social media forums of Twitter and Facebook, I put the question out there as to what is the single most important issue for psychiatry today. Mostly, the answer I got was my own: access to care. Peter Kramer, a psychiatrist at Brown University, Providence, R.I., and author of “Ordinarily Well” tweeted that “finding disease mechanisms and finding related treatments” was important, along with access to currently available treatments. My most interesting response was from forensic psychiatrist Erik Roskes, who bluntly said on Facebook, “For someone like me, working in the trenches of our “system,” the biggest problem I see is advocates who think there is a simple solution to our problem. No offense, but asking this question is the problem, not the solution. Feel free to advocate, to be sure, but don’t be surprised when your suggested panacea does not work or is not tried, because it is too expensive and cannot compete with many other priorities that are important to advocates for other important causes.” Finally, a high school friend who works as a teaching assistant and has struggled with her own children’s issues has said the biggest problem is a lack of resources for parents of children with mental disorders.
So with a little reassurance that my ideas are not so far out of date, I’ll start my David Letterman list of what the biggest issues are for psychiatry today.
1. Access to care. No matter how wonderful our treatments are, the fact remains that they are inaccessible to many people, and those who are able to negotiate treatment often struggle to do so. This struggle to find care often comes at a time when people are depressed, psychotic, or vulnerable and often not their own best advocates. It involves bargaining with insurers, being led to believe that coverage is better than it is, and few options for the uninsured and underinsured, who often must rely on public health clinics – which often are not accepting patients or have long waits. Even those with insurance are sent a formidable list of participating providers, many of whom are dead, have relocated, are not accepting new patients, or have never been heard of by their agencies. And for the working individual who needs after-hours care, the struggle is even harder. Let’s not even talk about the number of voice mail prompts and time on hold that each call entails.
In half of all counties in this country, there are no mental health professionals at all, not just a lack of psychiatrists. So folded into the access-to-care problem, I’d like to include the fact that there are just not enough psychiatrists to see everyone who needs to be seen. As a shortage field, more than half of psychiatrists do not participate in health insurance plans, and despite long battles for parity legislation, this does little to help insured patients, who must go out of network, where they face high deductibles and low rates of reimbursement under designated “usual and customary rates,” leaving well-insured patients with very high copays, often amounting to no coverage at all, and often much to their surprise. Simply put, we need to make it easier for patients to find psychiatrists, and we need insurance to pay for psychiatric care.