We repeatedly hear warnings about the looming shortage of doctors, a crisis intensifying by 2014 when reform provisions allow 30 million people who now lack health insurance to afford medical care.
But who is paying attention to whether there will be enough specialists in behavioral or mental health to treat them all?
Emergency room doctors, primary care and family medicine caregivers are often the first to encounter behavioral or mental disturbances in their patients, but will they have enough training to recognize what they see, and what to do, especially when so many people who have gone so long without mental health care begin to seek it?
Additionally, health plans for the insured will be required to cover mental illness care just as they do now for physical illness under the Patient Protection and Affordable Care Act's "mental health services parity" provisions. Prior behavioral problems will no longer be reasons for exclusion.
All these factors "will stretch the health professions to levels we haven't ever seen," says Sergio Aguilar-Gaxiola, a professor of clinical internal medicine at UC Davis Medical Center Health System and a community psychologist. "We don't have enough primary care providers to deal with what I call a tsunami of newly needed services for those 30 million newly insured."
As anyone who has ever worked in a hospital or clinic knows, mental illness—frequently exacerbated by cycles of drug or alcohol abuse and homelessness—is often a subtle, underlying problem in a large segment of their patient mix. That's especially true in larger inner city settings, but it is also true—perhaps to a lesser extent—everywhere else. It takes a degree of skill to recognize it.
Aguilar-Gaxiola is a co-author of a survey report from the UCLA Center for Health Policy Research that quantifies how bad the problem may truly be.
One in five adults surveyed said they had needed professional help for a mental or emotional problem within 12 months of the survey. And one in 25 reported one or more symptoms associated with serious psychological distress, based on the number of times in the last 30 days they felt nervous, hopeless, restless or fidgety, worthless, so depressed that nothing could cheer them and that everything was an effort.
The report is drawn from the California Health Interview Survey, the largest state health questionnaire in the nation. The survey was conducted by the UCLA Center for Health Policy Research, which collected health related responses through telephone interviews from nearly 50,000 adults in the state, a process undertaken every two years.
Extrapolating the findings to California as a whole, the researchers discovered that 4.9 million California adults said they needed help for a mental or emotional health problem in the last year and one million reported symptoms associated with serious psychological distress in the last 30 days.
Yet only one in three of those who reported these mental health issues actually visited a mental health professional for treatment, in part because of fear of stigma, and in part because of lack of insurance coverage, the survey said. The problem is especially severe among Latino and Asian immigrants.
Additionally, this was the survey's snapshot for 2005, several years before the recession and the historic rise in the number of unemployed, which created economic pressures that have undoubtedly made the problem much worse.
"In the U.S., mental illness accounts for approximately 25% of disability and is a leading cause of premature death," the UCLA report says. "Aside from reducing overall year and quality of life, untreated mental illness has been associated with suicide, substance abuse, homicide, heart disease and other medical conditions, work or school problems, family conflicts, relationship difficulties, social isolation, poverty and homelessness."
Aguilar-Gaxiola says that in many cases, people who have mental health issues often seek care because they are having symptoms and know something is wrong, "but they don't know they have a mental disorder and don't describe what they're feeling or their symptoms like that. Instead, they describe it as a physical condition."
There is emerging evidence, he continues, "that the coexistence of mental conditions with physical conditions is the rule rather than the exception. When these patients come to the emergency room, they present with specific aches and pains, and it is up to the emergency room specialists to sort that out."
He adds, "If we had more behavioral health providers co-located in these emergency rooms, more often these patients would be appropriately triaged and treated more appropriately. But that is not the case. Unfortunately, this tends to be very expensive, and now, providers are in budget cutting mode."
Stephen Mayberg, director of the California Department of Mental Health which funded the UCLA study, notes that "Some people with mental illness are not taken seriously by physicians when they have a physical complaint because they have mental illness. Other people with a mental illness who do not have access to medical care often develop chronic health conditions."
Aguilar-Gaxiola also indicated that medical training needs to improve the way it trains future doctors by better equipping them to recognize these subtle distinctions and treat patients' physical and mental health issues more effectively.
"Psychiatry continues to play a minimal role in medical training years," he says. "And the end result is that even though a good proportion of people who will be seen in these settings have mental health conditions, doctors often aren't trained to identify and deal appropriately with them."
Aguilar-Gaxiola says that care often suffers because the health system is "so fragmented. Patients are seen in one place by one provider for their physical problems, but they're seen in another place by another provider for their psychological problems."
And while health reform will prompt many more patients to seek care, he thinks that federal provisions that emphasize the creation of more integrated models "will allow us to move more decisively and effectively" into delivering care that treats both physical and mental diseases and disorders in the same place, at the same time.
Let's hope he's right.