Lack of access to evidence-based mental health care poses grave threat

Jack Resneck Jr., MD , Former President

The recent release of more than $300 million in federal funding by the White House to bolster mental health staffing in schools and foster behavioral health integration in clinical practice is a critical step in a long journey toward solving a mental health crisis that has been decades in the making.

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The evidence is everywhere. A survey released by CNN and the Kaiser Family Foundation (KFF) showed that nine in 10 U.S. adults believe the nation is experiencing a behavioral health crisis. Roughly half of all respondents said they experienced a severe mental health issue in their own families. Days earlier, the Centers for Disease Control and Prevention reported an alarming increase in the suicide rate, with the largest jump occurring among males 15–24 years old.

The U.S. surgeon general has highlighted the urgent need to address a mental health crisis among young people, including increased suicidal behaviors. Those most at risk are adolescents and young adults, LGBTQ+ people, individuals from historically marginalized racial and ethnic groups, and those in the child welfare or juvenile justice systems. The COVID-19 pandemic has only exacerbated this mental health crisis, with many experiencing increased anxiety and depression, isolation, job insecurity, intimate partner violence, challenges accessing health care and a host of other stressors.

The pandemic aggravated a longstanding and unaddressed nationwide crisis in mental and behavioral health, and a significant contributing factor has been the ongoing shortage of mental health professionals. A KFF assessment of the nation’s mental health workforce found that more than one-third of the U.S. population lives in areas that are underserved by these professionals; about 80% of rural counties lack even a single psychiatrist.

Lackluster enforcement of the Mental Health Parity and Addiction Equity Act is a significant factor driving this crisis. Enacted in 2008, this law specifies, among other things, that benefits for substance use disorders and other behavioral health conditions cannot be more restrictive than medical or surgical benefits. But an annual federal review shows that insurers consistently fail to comply with this law, and that their violations have become more numerous and egregious.

As a result, millions of patients have been harmed by parity failures, and this harm will continue until insurers are held accountable for their actions. In addition to AMA advocacy supporting enforcement of parity laws, the AMA has also urged state departments of insurance to take enforcement actions under network adequacy laws to ensure access to mental and behavioral health care.

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Increasing the size of the mental health workforce is an important, complex, and highly challenging task requiring thoughtful solutions. But complexity isn’t an excuse for further delay in addressing the unacceptable lack of mental health access.

Creating more residency slots in psychiatry is one vital, overdue step. The Consolidated Appropriations Act of 2021 included funding for 1,000 new Medicare-supported residency training positions across all specialties combined, which represented the first significant expansion since 1996. We need far more expansion in residency training capacity, including psychiatry positions. Fortunately, there are positive signs of growing interest in the specialty—the Association of American Medical Colleges reports that the number of psychiatry residents has jumped by twenty percent in the last several years, with nearly twice as many applicants as available positions this year alone.

With up to 70% of all care visits including a behavioral health component, primary care physicians are important and substantial contributors to screening for and addressing behavioral health conditions. Accelerating Behavioral Health Integration (BHI) in physician practices will be essential to addressing the unmet needs and coordinating with the expertise of psychiatry colleagues.

Payers and policymakers must act urgently to ensure primary care physicians and their care teams have the support they need to provide coordinated, equitable care for their patients and families. This includes providing long-term sustainable funding for training and education for physician practices on implementing BHI, limiting harmful health plan utilization-management review practices for integrative services, and improving insurer network adequacy.

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The AMA continues to empower physicians and their care teams to improve the quality of care and expand patients’ timely access to equitable care through BHI. This helps improve access to behavioral health screening and coordinated treatment, promotes whole-person health, and reduces the risk of self-harm and suicide.

BHI can also improve physician well-being and reduce burnout. Physicians offering these services know they are providing essential care for their patients’ most pressing needs and addressing a critical gap in the health care system.

The AMA has created resources to assist physicians in integrating behavioral health services into their practices. These include comprehensive practice how-to guides with proven strategies on effective integrated care as well as a coding guide outlining key billing codes physicians and their care teams can use when administering integrated services.

The AMA has also partnered with seven other physician organizations, including leaders in psychiatry and primary care, to create the Behavioral Health Integration (BHI) Collaborative dedicated to equipping physicians and their practices with the necessary knowledge to overcome obstacles and sustain integrated care for their patients and families. This partnership has yielded numerous resources including the BHI Compendium to guide practices through the steps of delivering effective integrated care. The Collaborative also offers free enhanced technical assistance directly to physician practices on how to effectively implement BHI through its BHI Immersion Program.

Telepsychiatry, which saw dramatic expansion during the COVID-19 pandemic, is another essential strategy to improve and increase access to high-quality, evidence-based mental health care. This has been particularly important for historically marginalized communities that face barriers to access, and the AMA is advocating for continued coverage of high-quality, seamlessly integrated telepsychiatry delivered by physicians and physician-led teams.

The pandemic has changed our world, and we must improve our response to meet the expanded need for behavioral health care demonstrated by our patients of all ages. As the physician’s powerful ally in patient care, the AMA will continue to have physicians’ backs in meeting the physical and mental health needs of our nation.