PRINTThe waiting game
Demand outweighs access in Columbia’s mental health care system
Clay McGlaughlin
In this photo illustration, patients pass the time in a waiting room.
April 9, 2009 | 12:00 a.m. CST
Ten years ago, Jacob Zagorac went to see several doctors because of heart-related irregularities. Zagorac’s heart would race at times, he had palpitations, and he would break into sweats. But none of the doctors could figure out what was wrong with him. Not until seeing a psychologist in Jefferson City was he diagnosed with depression and anxiety. “That’s the thing,” Zagorac says. “Mental illness is so elusive.” It was not the first time Zagorac, 29, was diagnosed with a mental illness, nor was it the last: His most recent battle with depression lasted from 2003 to 2008. Since the ninth grade, he has been diagnosed with several different mental illnesses, including major depression, borderline personality disorder and bipolar disorder. He received psychotherapy and 17 different types of medication over time, none of which worked, he says. Eventually, he found solace in spirituality.
Now Zagorac works part time as an aide at Mid-Missouri Mental Health Center, where he was once a patient. He also runs his own business as a happiness coach, where he applies spiritual teachings to help those suffering from mental illness, though he prefers the term “emotional suffering.” He is neither a counselor nor a therapist but believes the two professions have the same intent: to help those with mental illness enjoy life. He doesn’t think there is anything wrong with medication if it helps patients, but he wants to help those for whom medication is not the answer, he says.
Although Zagorac never had trouble finding counseling or care, it is becoming increasingly difficult for people to access mental health care in Columbia, in Missouri and across the nation. Much of this has to do with the economy: Stressful times create the need for more counseling and thus greater demand. But there are also the problems of diminishing services, a psychiatrist shortage on the local and national scale and a lack of insurance. Mental illness is like a weight, and without counseling or treatment, it is a weight those suffering can find difficult to carry.
ECONOMIC FACTORS
In October, the American Psychological Association reported that almost half of Americans say they worry about whether or not they can provide for their family’s essential needs, and eight out of 10 say the economy causes them a significant amount of stress. People are also finding it difficult to afford mental health care as they lose jobs and subsequently income or insurance that could pay for counseling services.
“We live in very stressful times,” says Jeanette Parker, treasurer for Columbia’s chapter of the National Alliance on Mental Illness. “This is a poor economy, and I think that when people are under stress, they seek out help.”
As people become more anxious about losing their jobs and grow uncertain about whether they will be able to continue to provide for their families, counseling becomes an appealing option to help them cope. “Things they were able to do before are becoming more difficult: feeding their families, putting a roof over their heads, basic things,” says Lisa Thomas, a psychiatrist at Truman Veterans Hospital.
Exact numbers are hard to come by, but local counselors are hearing about an increase in demand for mental health services in Columbia. “I think that the end result is that there will be more people seeking therapy,” says Michael Mayer, a Columbia-area psychologist. “It’s really hard to tell. We don’t have any figures before and after, but I would say the answer is yes.”
Ted Solomon, outpatient program director of the Family Counseling Center in Columbia, agrees. “When I say there’s an increase, I would say it’s either the same or more,” he says. “It’s not less.” But Columbia might be ill-equipped to meet the growing demand for affordable counseling services.
“The people who are the most vulnerable are the people who don’t have much money or insurance,” Solomon says. His facility provides counseling to both insured and uninsured patients. Costs are determined on a sliding scale by income and family size for those without insurance, and sessions can cost anywhere from $7 to $80.
However, the center also has a waiting list of more than 100 people. At the beginning of March, an insured person could expect to wait around two months for an appointment; an uninsured person would wait twice as long. “We do have a long waiting list for folks who don’t have insurance,” Solomon says. “That’s probably the longest piece of our waiting list. It’s likely that they’re not going to have an easy time getting squeezed in because we are pretty well-funded for our waiting list and our sliding scale, but we’re not well enough funded for the demand.”
The Family Counseling Center, which has a staff of six full-time counselors and three psychiatry residents from MU who perform part-time rotations, receives most of its funding from the city and the United Way. “They’re very generous with us, but it does not meet the demand for the services we have, for sliding-scale services,” Solomon says.
Another option for those seeking counseling is a private practitioner. Patients won’t have long to wait for service, but a session with a counselor who holds a doctorate generally ranges from $90 to $110. A session with a master’s-level counselor can range from $75 to $90. Mayer, who runs his own practice, says that he occasionally has patients who need more than a few sessions to resolve their problems. He points out that insurance will not cover counseling sessions unless the patient has a diagnosable problem, but patients have the option to self-pay.
MISSOURI’S PROGRAMS
Mental illness is not rare, even in a positive economy. According to NAMI, one in four adults experience a mental disorder each year — that’s approximately 57.7 million Americans. Yet less than one-third of adults and half of children who can be diagnosed with a mental disorder receive mental health services. Furthermore, according to NAMI, racial and ethnic minorities are likely to have less access to mental health services and often experience an inferior quality of care.
NAMI gave Missouri a C in its 2009 mental health care report card, the same grade it received in the previous report from 2006. No state received an A, and the national average was a D. According to the report, which graded the states based on 65 criteria, Missouri cut more than 100,000 people from Medicaid in 2005 and 2006. Since then, no adults have had their Medicaid restored.
The state is also making major cuts to its mental health funding. For fiscal year 2010, the Missouri House Budget Committee proposed $58 million in cuts from the Department of Mental Health. According to the DMH, these cuts would force the elimination of services for more than 13,000 Medicaid-eligible and uninsured Missourians with developmental disabilities, severe mental illnesses and alcohol and drug addictions.
The cuts, if carried out, will result in the loss of hundreds of jobs in Missouri’s mental health care field, which could spread services funded by the DMH even thinner.
Furthermore, as many as 2,930 Medicaid-eligible individuals with “serious and persistent” mental illnesses, such as schizophrenia, bipolar disorder or major depression, could lose their funding. According to the DMH, “These are lifetime illnesses that require ongoing community case management and support, including medication management, psychiatric care and housing.”
Choice is limited for those with no insurance or income. Thomas says that the Department of Veterans Affairs anticipates receiving more patients who until recently had relied on outside resources, such as benefits and insurance from their civilian jobs. Mayer says that many people faced with a choice between paying for mental health care and paying for something else will not choose mental health care.
“We ask advice on so many other things,” he says. “We don’t try to fix our car. We don’t try to say we know everything about our religion. We don’t try to say we know everything about our physical problems. So maybe you do need to ask a psychologist or a therapist about how to deal with this emotional part of our life.”
Another problem in Columbia is the lack of private-practice psychiatrists. Thomas says a private-practice psychiatrist is also something of an entrepreneur and must factor in expenses including office space, employees and insurance paperwork. She adds that most people go into psychiatry so they can treat patients, not run a business.
But psychiatry might not be as financially desirable as other medical fields. Salary.com places the 25th percentile salary for radiologists at around $310,000 a year. For orthopedic surgeons, the 25th percentile earns around $307,000. The 25th percentile of psychiatrists, by comparison, earns about $157,000 a year.
ADDITIONAL CONCERNS
Other factors besides insurance or income can influence whether a person will receive mental health services. Thomas says the stigma surrounding mental illness figures into people’s perception of counseling. “Some people just will not use services because they don’t want the mental health label,” she says. “They don’t want to be seen as someone who needs emotional or psychiatric health [care] in some ways.”
Distance can also be a factor with most mental health resources located in Columbia. If those in the outer reaches of Boone County do not have a vehicle, have unreliable transportation or can’t afford gas, access to mental health care becomes even more problematic.
After-hours services are also meager. “The few private-practice people who are around don’t have a lot of after-hours or Saturday availability,” Thomas says. “Even in our hospitals, the outpatient programs, things appear to be pretty much Monday through Friday.”
The situation might be even more dire for those in crisis mode who might be suicidal or homicidal and require more care than a single counseling or diagnostic session. Tim Harlan, president of NAMI Columbia and vice president of NAMI Missouri, says Columbia has around half the psychiatric beds it had 20 years ago. This is because hospitals receive more reimbursement from Medicare and Medicaid for physical procedures, such as hip replacements and heart surgery, than for more diagnostic disciplines such as psychiatry.
To deal with reduced services and increasing demand, Mid-Missouri Mental Health Center is on diversion. That means whenever the hospital is full, new cases are sent to another care facility, sometimes as far as St. Louis. To Harlan, this arrangement creates a dangerous choice: Either send crisis patients home with a prescription and trust they will take it, or send them on a two-hour drive and hope they’ll be OK.
More than a year has passed since Zagorac was a patient at Mid-Missouri Mental Health Center, and he still attends NAMI meetings though no longer as a consumer. He attends group support for family members of those with mental illness, and he has even started his own support groups in Jefferson City. Six months ago, he became medication-free. “I believe it works for some people,” he says. “But it never worked for me.”
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