(Lack of) Mental Healthcare and What To Do?

[UrbanHealthRN, BSN, RN]

Hello All!

So just as quick introduction, I've been a nurse for about 4 years, working in pediatrics the entire time. For the last two years, I've been working in one of the primary care clinics in my city. Our pediatric department serves mainly kids who are on one of the state health plans. It's not always great, but compared to all of our patients with no insurance, I'll take it!

For me, one of the most frustrating things about public insurance is the limited selection of specialists we can refer our patients to, especially in the area of mental health. I feel like we use the same handful of mental health facilities all the time because there's no other places that accept our patients' insurance (believe me, I've checked!), and as a result our patients wind up with very long wait times before they can see a mental health professional of any kind, let alone a psychiatrist, who we usually want them to see.

There's one patient we have in particular whose mom is extremely frustrated about this lack of accessibility, and I don't know what else I can do to help. He's a teenager who first came to us back in May. Mom had recently moved to the area, and while he was regularly seeing a therapist, the therapist felt he needed a psychiatric evaluation for some problems with depression that were not resolving. This boy, besides experiencing depression, also has a history of Asperger's and something else psych related that I can't remember right now. In May, mom was under the impression that she would immediately be able to see a psychiatrist and have her son evaluated, even though I tried to explain that most psych places have a whole intake system/ long wait time that makes immediate help almost impossible, especially for someone who is not in acute crisis. She was not happy to hear this at all. I called almost ten different places for her, trying to find out what insurance they accepted, what the intake process was like, etc. and gave mom all this information. I really wanted to help her, especially since she was new and unfamiliar to the city.

We haven't heard from or seen this boy and his mom since, until tonight, when mom walked in an hour before closing with one dose of Prozac left for her son, asking for a refill. She told me that none of the places I told her about were acceptable to her due to long wait times to see a psychiatrist, and that for the past three months she had been paying out of pocket to see a psychiatrist, which is now no longer an affordable option for her. She wanted to know if her son's pediatrician could continue to prescribe the Prozac. I explained that neither of our pediatricians manage depression medication for their patients, as it is recommended that pedi patients have their management be done through a psychiatrist. This wasn't an acceptable answer for her, so I actually took the time to put her in a private exam room so she could speak with the doctor for almost half an hour, no appointment or anything. Of course, he told her he wouldn't be refilling the medication. When I gave her the contact information for our own organization's mental health worker, who is certainly better than me at coordinating psych care for patients, she was again very upset and basically told me that nobody was doing anything to address her son's depression and that we more or less didn't care. Then she left.

For whatever reason, even though she's been rude to me and seems to have some problems with prioritizing her son's needs (one pill left? Really?), I really feel bad for this mom. She's by herself with her special needs son, living in a new place, and because of her son's public insurance, he doesn't get to enjoy half the benefits a kid with private insurance does. I really feel like I went above and beyond for her back in May, calling agency after agency when other places would just hand her a list and tell her to do it herself. We see hundreds if not thousands of kids in our practice, and yet I remembered her the moment she came in tonight and took the time to listen to her frustrations.

My question is, what do the rest of you do in situations like this? How difficult is it in your area for patients to access mental health services? Even though she was pretty rude to me tonight and really didn't seem to understand that help can't come immediately, and that our pediatricians are not mental health specialists, I still find myself wanting to help and feeling bad for our kids who get waitlisted for everything. What do you all think?

[LakeEmerald]

Sounds like she had plenty of time to act on her son's behalf with the information you provided, and didn't. Now it's your fault. Wrong!

[xoemmylouox, ASN, RN]

People with private insurance face similar barriers. If the mental health provider isn't on your insurance network you pay out of pocket. People with private often pay big bucks even when the provider is in-network. In my experience the biggest problem is finding mental health care for kids, regardless of insurance. This Mom has a tough situation. Most of us do. You plan ahead if at all possible. There is only so much we can do.

[OrganizedChaos, LVN]

I have private insurance & I was trying to find someone in my network. I probably called close to ten psychiatrists before I finally found one that was taking new patients. That was a fun day. :-/

[blondy2061h, MSN, RN]

This is going to get worse with the affordable care act. And yes, people with private insurance have long wait times too for certain specialties. I don't understand why she wouldn't have paid for a private psychologist while also getting on the waiting list for a psychiatrist her insurance would pay for. Further, I also find it bizarre that the primary pediatrician won't give him refills to last til he gets in with a new psychiatrist on a depressed teenager established on meds. It sounds like this lady has some unrealistic expectations.

[Altra, BSN, RN]

I don't understand why she wouldn't have paid for a private psychologist while also getting on the waiting list for a psychiatrist her insurance would pay for.

A psychologist does not write prescriptions. And I believe OP discussed that this mom had been paying out of pocket to see a provider, but had exhausted her financial ability to do so.

It is unfortunate that the pediatrician would not write one 30-day script ... but that is his/her prerogative ... or the policy set by the practice.

[VivaLasViejas, ASN, RN]

Unfortunately, if one is not in the middle of a crisis, it's harder to get in to see an actual mental health professional. That's because there is a shortage of psychiatrists in this country, and the relative few who are available can be fussy about insurance. Reimbursements are low---that's why co-pays are comparatively high for specialists---and if you're talking about Medicaid, doctors almost LOSE money treating these patients.

I wish I had some words of wisdom, but I think you did all you could for this mother and her son.

[blondy2061h, MSN, RN]

A psychologist does not write prescriptions. And I believe OP discussed that this mom had been paying out of pocket to see a provider, but had exhausted her financial ability to do so.

It is unfortunate that the pediatrician would not write one 30-day script ... but that is his/her prerogative ... or the policy set by the practice.

I miss typed. I meant I didn't understand why this mother wouldn't pay for a private psychiatrist while waiting to get in with the covered psychiatrist. It sounds like this person went to the private psychiatrist instead of attempting to get into the covered one.

[Hayesallen]

I do not work in pediatrics, however, it is still a long wait for an appointment with psychiatrists or mental health nurse practitioners in our area. Our primary care usually alway provides medication rx (for uncomplicated depression) and follow up with telephone assessments (done by the RN); until the patient gets into their first mental health appointment. As long as the patient is compliant and does not miss their first scheduled appointment with the psychiatrist, this seems to work well for us.