Psychiatric Care Is Impossible to Find. Urgent Care Clinics Provide the Solution

During the past year, two of my old friends have been calling for advice on how to navigate the mental health system with a child in crisis. One child is preschool aged and was “tantruming” for 75% of his waking hours for over a year, and was suddenly worse. He would scream and writhe around on the floor for hours. The other was a teen who cut herself with a razor and told her parents she heard voices and wanted to die. These are serious situations in need of psychiatric opinions. Neither family could find the help they needed.

They faced the impossibly difficult decision of considering hospitalizing the child just to get the expert opinion. One family opted for hospitalization, where their child was locked in (and they were locked out) of a secured facility, and although the child was placed on psychiatric drugs to stabilize symptoms, the parents still never directly spoke with a psychiatrist to hear advice or even education about what caused the symptoms in the first place. They left the hospital without securing an outpatient appointment, and just hours after they got the child home, it was clear that the treatment wasn’t working and there was no one to call.

“Why has it become so impossible to access mental health care services?” was the question both families asked. 

I wish I fully understood the answer to that question. It seems many factors have contributed to the growing state of impossible access to psychiatric services. Foremost among them, there just aren’t enough psychiatrists. Filling psychiatric residencies is nearly impossible; it’s not a prestigious or high paying medical specialty. And then as the public raises awareness and encourages those in need to seek out psychiatric help, the need is increasing and no new providers are available to meet the increased need.

But training more doctors won’t meet the need now. Premed, medical school, and then residency training take a total of about twelve years. We can’t wait more than a decade for a solution. Physician’s assistants, psychiatric nurse practitioners, and primary care physicians, can fill part of the need, but will always need psychiatric physicians to advise them.

To meet the need, psychiatry is going to have to change. Psychiatric physicians are going to have to alter the dated model for delivering mental health care. We cannot just work faster and see patients in 3-minute time slots to fill this need. We are going to have to be innovative to find a way to address the need. 

Here are ways to expand access now:

1.    Psychiatrists can provide case consultation services to primary care physicians to help them stabilize and manage complex cases.
2.    Psychiatrists can offer one time clinical “second opinion consultation ” services to aid in diagnosis and treatment planning, and them allow other professionals to manage care long term.
3.    Psychiatrists can work closely with well-trained physician extenders in their outpatient clinics.
4.    Psychiatrists can offer educational and support services to the public, and to other providers.
5.    Psychiatrists can coordinate medication refill services for stable patients with primary care, so that unstable patients can be seen in open/available time slots in the psychiatric clinic.
6.    Psychiatrics can shift to specialized, short term urgent care clinic models with referral of stable patients back to primary care.

Psychiatric Urgent Care
The typical scenario for people seeking mental health care services in my community progresses as follows: 
1.    An unexpected crisis hits, so the individual in crisis seeks care at an emergency room or medical urgent care. A doctor or PA assesses the patient and may recommend hospitalization, but usually not. (Mental health hospitals provide care for a few days when necessary for safety. If there is not a safety concern, hospitalization is usually not the best option). The doctor/PA perhaps prescribes a Xanax like medication (probably not the best treatment for he problem, but available in the ER) and recommends ongoing care with a psychiatrist, but doesn’t know anyone who is taking new patients.
2.    The patient, hopefully stable enough to wait, calls around town and finds out very few psychiatrists accept her insurance, and many of those who do take her plan have full practices. She finally finds someone and schedules an appointment with psychiatrist’s office, but will have to wait 4 months for the initial evaluation.
3.    Uncertain she can wait 4 months; she reluctantly goes to her primary care physician (to whom she had not wanted to disclose the psychiatric problem, because she felt ashamed). The PCP starts a medication, but both he and the patient feel uncertain that they understand the problem fully and both would prefer the opinion of a specialist, which they must wait 120 days to hear.
4.    When she does finally meet with the psychiatrist, she finds that this person is not a good fit for her needs. He’s a specialist in PTSD and mostly treats veterans with medications only. He has 10-15 minute appointments. The patient is a 50-year-old woman with depression, and she wanted longer sessions with her doctor. 10 minutes is not enough time to get her concerns heard. She also preferred to see a female psychiatrist, but couldn’t find one who was taking new patients.

The mental health urgent care center, the scenario can look quite different.
1.    A crisis hits and the patient seeks care at a same day or same week appointment. She is assessed by a team consisting of a therapist and psychiatrist, and a treatment plan is developed which includes both short term psychotherapy and starting an antidepressant. She may also be referred to a group for psychotherapy.
2.    As part of the treatment plan, a long-term strategy is developed for the patient’s continued care. Her choices for care include returning to primary care to maintain treatment once her symptoms are stable, having the mental health urgent care center facilitate an appropriate referral to a psychiatrist who provides the services she needs, or waiting on a waiting list with a community provider while the MHUC provides bridge care in the interim.
3.    The MHUC stabilizes the patient, decreases emergency room and hospital utilization, and offers a screening process for the patient so she can land in the right place for care.

Psychiatrists can offer consultation at the onset of an illness, and then allow other professionals to continue the plan later. Urgent care centers may be the best way to deliver specialty care in other fields as well (like orthopedics and internal medicine diagnostics), so that brief periods of consultation can then be followed by longer-term follow-up in primary care.

Posted on August 8, 2016 .