Two-thirds of 6,600 primary care physicians surveyed in 60 U.S. communities
said they are unable to obtain outpatient mental health care for their
patients, according to a report by researchers from the Center for Studying
Health System Change (HSC) published in April's Health Affairs.
The researchers discovered that the mental health treatment difficulties
occurred far more frequently than referrals to other types of health care
services. They also found that mental health manpower and inadequate insurance
coverage play a big role in the problem.
"From the perspective of primary care physicians, the study's
findings suggest that lack of access to mental health services is a serious
problem—much more serious than for other commonly used medical
services," said Peter Cunningham, Ph.D., a senior fellow at the HSC and
an author of the study, in a written statement.
Based on the survey, conducted in 2004 and 2005, Cunningham and his
colleagues found that mental health referrals proved more elusive for the
primary care physicians surveyed than other kinds of medical care referrals,
including specialty non-mental health care. Specifically, the rate of
difficulty in obtaining needed outpatient mental health care for patients was
more than twice the rate reported for any of three other common referrals:
other specialists, imaging services, and nonemergency hospital admissions. For
example, almost 67 percent of the primary care physicians reported that they
couldn't get mental health services for some of their patients, compared with
34 percent who reported other non-mental health specialist referral obstacles,
30 percent who reported they couldn't get diagnostic imaging, and 17 percent
who reported they were unable to obtain nonemergency hospital
Primary care clinicians cited inadequate health coverage, "insurance
barriers," and an inability to find a mental health clinician to care
for their patients, among the chief reasons their patients could not obtain
care for psychiatric conditions.
Among primary care providers, who included general internists, family and
general practitioners and pediatricians, the pediatricians were more likely to
report problems in getting mental health care for their patients.
Pediatricians cited a shortage of providers for children and health plan
barriers such as a lack of coverage for mental health services.
The study consistently found a lower number of psychiatrists in areas of
the country where there were more problems getting mental health services due
to a shortage of providers. Physicians in counties with moderate or large
numbers of psychiatrists (defined by the authors as at least eight
psychiatrists per 100,000 residents) were about 12 percent less likely to
report provider shortages as one reason for the lack of available mental
health referral care than were clinicians in counties with fewer
The authors were surprised that counties with a high number of
psychiatrists had a greater probability of patients being denied mental health
care because of either "plan barriers" or inadequate or a lack of
coverage among patients compared with counties having smaller numbers of
psychiatrists. Although areas with large numbers of psychiatrists were likely
to have greater mental health care utilization overall, the authors theorized
that health insurance plans in those locations may attempt to limit the
utilization of psychiatric care through greater restrictions on utilization or
less generous benefits.
The study "clearly is an indicator that there are ongoing problems
with access to mental health care," said Anita Everett, M.D., chair of
APA's Council on Healthcare Systems and Financing.
Still, in many areas with small numbers of psychiatrists, the researchers
found that the shortage of such clinicians had a greater impact on the ability
to obtain mental health care than did obstacles stemming from a lack of
coverage and from insurance-plan barriers.
Problems accessing mental health care that stemmed from a lack of
insurance—and underinsurance by policies that provided no or lesser
mental health care coverage—were most often cited as factors in patients
not receiving needed care. It is not known yet whether access to mental health
care was enhanced by the federal mental health insurance parity law enacted in
2008, said the authors. They concluded that state mental health parity laws
have had only a modest effect on reducing mental health access disparities
when compared with states that do not have insurance parity laws.
"Even with national parity legislation, large gaps in mental health
access will likely remain, and the new law will have no effect on the severe
access problems of the uninsured as well as problems related to the shortage
of mental health care providers," Cunningham and his coauthors
"Beyond Parity: Primary Care Physicians' Perspectives on
Access to Mental Health Care" is posted at<http://hschange.org/CONTENT/1054/?>.▪