Ep. 43 - Why Getting Mental Health Treatment Is Harder Than It Should Be

Getting help sounds simple until you actually try to do it. Dr. Rosen and Dr. Gross walk through the less obvious reasons people hesitate, from shame and privacy concerns to the quiet belief that we should be able to handle things on our own. It’s not the same as going to a dentist or fixing a car, and people feel that difference in a very real way.

They also get into what happens once you decide to reach out. Insurance limitations, mismatched referrals, short treatment windows, and medication hurdles can turn the process into something frustrating and discouraging. Even finding the right kind of help can feel like guesswork if you don’t know where to start.

There’s a practical side to this too. Starting with a primary care doctor, ruling out medical causes, and looking for specialists who actually match the problem can make a difference. But even those steps come with tradeoffs depending on cost, access, and availability.

Underneath all of it is something both of them come back to often. Mental health is harder to see, harder to define, and easier to misunderstand. But people do get better. Even when it doesn’t feel believable in the moment, that possibility is still there.

Contact the Docs:

Email: twoshrinksandamic@gmail.com

Transcript

SPEAKER_01 0:04

Hi, I'm Dr. Andrew Rosen, I'm a psychologist.

SPEAKER_00 0:08

And I am Dr. David Gross, I'm a psychiatrist, and today we're going to continue a discussion about some of the difficulties in obtaining treatment, uh, obstacles to treatment, which uh wide spectrum, wide variety of issues that get in the way. Uh but we are two shrinks and a mic.

SPEAKER_01 0:26

Good afternoon. Yeah, I think um ordinarily one would not necessarily think that there would be obstacles to getting mental health treatment or good mental health treatment, but uh it's not easy. And there are many factors involved with that. Um some are psychological, meaning that a person who may think that I have some problems I need help with. Uh we talked a little bit about in the past that some of the psychological obstacles happen to do with shame and embarrassment and and the idea that uh we should not need help from anybody else, that we're if we're good, strong human beings, we can handle it ourselves and figure things out and and not need to rely or lean on anybody else. So some of that mentality is still, you know, very strong and um and probably in every culture, but some more than others. And that's a big sort of psychological obstacle to saying I need help with this. We don't have it when it comes to deciding that I need help figuring out my taxes. We don't have it when it comes to I need somebody to fix my car. We don't have it with I think I need a root canal. I mean, we don't care about doing things. Right? So when it comes to those things, we're quite willing to trust other people. Uh, but when it comes to psychological help, I should not need help from anybody else. So that's one psychological obstacle. And then there are many other situational and practical obstacles that we can and we will discuss.

SPEAKER_00 2:02

One of the other aspects, uh, which is a real practical one, is what's called access to care. Um and access to care is a multi-pronged problem, one of which is uh financial. Um insurance companies do cover mental health care, but they're often very, very specific about approving their providers. And that's where part of the uh difficulties come in, because if uh you just call up your insurance company and ask for a therapist, um you you may not get the exact type of therapist that you need for the nature of the problem. Um, because, for example, if a person has uh uh an anxiety disorder and would benefit from cognitive behavioral therapy in a specific form of treatment for the anxiety disorder, and instead they get referred to a uh a general psychotherapy-oriented therapist, it's not going to be as uh cost-effective and and helpful. Um and then, of course, uh are there clinicians in your area? Uh there's been concern around uh our country in terms of people who live in an underserved area where they don't have the number of mental health professionals that uh that need to be uh present at the time. Um one of the things that has helped that has been the presence of uh uh telehealth, you know, where you can communicate with a clinician uh virtually uh over the internet, uh, which uh makes access to care in underserved areas much more effective. Um but the other the other aspect of it is um making sure when you de some do see somebody on your insurance plan that the the the individual does a comprehensive evaluation to help with your with your help figure out exactly what's going on so you can put together a treatment plan. There has been a tendency in our field, both psychology and psychiatry uh and masses level mental health professionals, to fit the treatment to the person rather than coming up with a diagnosis first and then coming up with a treatment plan. But they're individuals who get trained in a certain type of therapy and they apply, you know, one size fits all type of approach. And so the uh uh obstacles to treatment are uh are varied and and uh uh require some some thought as you obtain mental health care.

SPEAKER_01 4:25

Yeah, I guess we d need to think of it in terms of there's obstacles to treatment and then the obstacles to appropriate and good treatment. And um the first order of obstacles has to do with the person's own reasons for being hesitant to get treatment. You know, for instance, the other day there was somebody uh who came to see me, it was a professional, and he was very hesitant to uh see me because I might take notes, and if I took notes, it would get in somehow into his record. And what if that personal information in his record somehow got out to his um professional community, et cetera, et cetera? And then even more so, what if that information got out that he was seeing a psychologist and that might affect a family member's uh future goals with career choices, et cetera? So when it comes to this type of treatment, people are very fearful. Uh if it was some other reason, nobody'd be asking questions about the what's in my uh what's in my notes or in my chart. They wouldn't care if I was the eye doctor or so-and-so. So that's one big um kind of fear mechanism that people have is like, what's the consequence of me getting help? Number one. And number two, uh, then there's the the financial part of it. People in general hate spending money on health care. They just do. I mean, people will hesitate getting medication if it's expensive. People hate spending money going to any doctor, whether it's for uh general care or prevention, or even if it's uh they have a significant issue and they need to see a specialist, they'll hold off on it because they might really hate spending 200 bucks or 300 bucks on an office visit to any doctor where there's more specific uh uh care that they're going to get. Then on top of it, to spend money to go see a mental health professional where all I'm gonna do is basically talk, well, they're very, very hesitant to do that. So those are all obstacles. They get in the way. They're preconceived notions, they're old issues, they're old tapes that people have. But uh, when it comes to mental health care, they're really major issues and obstacles that uh keep a lot of people out of treatment. Once they get into treatment, then there's other obstacles. They may not, as you were saying, Dave, they may not get into the right clinician who might really know how to treat their particular problem.

SPEAKER_00 7:11

You know, because of the importance of uh figuring out as well as you can what's wrong, uh, it's always a good idea, I tell people regularly, to start with your family doctor. Because even though the family doctor is not a mental health professional, uh if you do a survey of most uh primary care providers, family doctors, they'll tell you that 50% of their practice is mental health care. You know, whether it be uh anxiety and depression over a life situation or anxiety and depression over an illness, a medical illness that they have. But the family doctor is capable of trying to hone in to some degree as to the nature of the problem and then come up with a recommendation. Um oftentimes there's a limitation there, and that is that that frequently it's easier to hand out an antidepressant as a one treatment treats all type of approach without paying attention to the need for other aspects of care like psychotherapy. But starting off with the family doctor is generally a good idea. And in addition to that, the family doctor usually has been working with the mental health professionals in the community and knows individuals that he or she can trust and will get feedback from and know will provide a decent level of care. Again, a lot will depend upon insurance coverage if that individual is uh in your insurance plan, but the family doctor can often steer you in the right direction. Um and and that that aspect of it is really important. Uh the family doctor may do a good job in determining whether this is a mood disorder, like depression or an anxiety disorder, and uh help decide whether or not treatment is necessary with a psychiatrist or a non-MD mental health professional. Uh so it's always a good idea to start there. In addition, it makes sense to uh look for medical uh causes of uh psychiatric emotional problems. For example, if you have significant anemia, you're gonna feel blue and down and have no energy and not be motivated. Um, if your thyroid is off balance, you can have problems with both anxiety as well as depression. So getting a a good assessment makes sense and oftentimes is fairly straightforward, requiring just uh laboratory testing that's not too complicated. But I always recommend that that's the first place to start.

SPEAKER_01 9:29

It happens more frequently than people realize. I mean, even just the other day, I heard about a situation where uh uh senior, an older man who was uh depressed, anxious, losing weight, not no appetite. And the assumption was it was related to the fact that he um was worried about getting older and he was retiring and uh uh thinking about whether he should or shouldn't, all kinds of issues going on like that. And uh the assumption was that uh this was all psychological and was related to a time of life issue. Uh but he finally went to his uh primary care doctor who did all kinds of tests, and lo and behold, they found out that he was severely uh deficient in vitamin B12. And that that was related to his lack of appetite and and weight loss, which then made him worry about his weight loss and so on and so forth. So it's really important to uh make sure that this isn't just a psychological, sociological event and that they're that it would screen out medical issues, but even still, like I was saying before, people don't want to go spend that extra buck at the family doctor, especially if they have a deductible and now it's going to come out of pocket. Um, so those are obstacles. There's and there's another obstacle related to that as well, and that is in in insurance or managed care, believe it or not, the uh number of office visits that you can have to a mental health clinician may be severely limited. You know, years ago, uh there was no limitation. Now, if you go to your insurance uh panel and look for a provider, uh you okay, they'll send you to Dr. So-and-so. And then uh based on the diagnosis, they may only give you five appointments or ten sessions or fifteen sessions. And the clinician needs to write all kinds of reports to the uh insurance provider uh as to whether or not more sessions are justified. So those are obstacles. If you were the average patient, would you want to make a commitment to going to a therapist where you may only be able to talk to the guy or the woman for three sessions? It gets in the way.

SPEAKER_00 11:54

The other aspect of uh care, especially for myself as a psychiatrist, since I prescribe medications, and that's a big part of the therapy that I can provide is is the difficulty when getting insurance companies to approve medications. Uh I think they figured out a while ago that the more roadblocks they can put up in approving medications, the less the cost to them. And and uh uh now it's uh uh practically almost 100%, where if I write a prescription for an antidepressant, um the insurance company will reject it and say there needs to be a prior authorization. And then what happens with the prior authorization is that we end up getting forms that have to be filled out, which requires time and effort, which we do, uh, do it routinely. And then oftentimes once you send that form in, it you find out that that was the initial form, and then they send in another more complicated form. Uh and and it it's uh it's a real problem. I mean, I just had an example with an individual who uh had attention deficit disorder and needed to be on a medication for that, and uh prior authorization was required, and uh the case was really straightforward uh for attention deficit disorder and uh filled out the forms and that got rejected. And then what I then subsequently found out was that the uh company told uh the patient that they need a letter from me stating that the medication is medically indicated, which is kind of absurd since that's the form I filled out to begin with. But you know, after a while you begin to see that this is uh uh a way to avoid payment. Because if if uh if you ever talk with the staff of a psychiatrist's office or even an internist office who have to get on the phone with insurance companies to approve a treatment, uh they'll tell you that they end up talking to a clerk who's not particularly sophisticated in the area that they need to be, and then they end up ending spending up a lot of time on the phone with them, uh valuable time and and getting nowhere and then saying, well, I need to speak to your supervisor. Well, the supervisor will call you back. So it's uh it's an onerous problem and there's no easy solution to it because it's understandable that insurance companies are in the business to make a profit, but it's gotten to a point where it's become very, very difficult. And um many many psychiatrists will say to patients, uh, you know, if you use uh goodrx.com, uh goodrx.com, worthwhile looking up that app, it's a uh free website that will give you the cost of medications independent of insurance. Sometimes the cost of out-of-pocket for medications is no different than the copay from the insurance company. And I'm sure the insurance companies are laughing all the way to the bank because goodrx.com not only saves them from having to shell out money to pay for medications, but they also don't have to spend the administrative time dealing with these claims. But it is an option. And a number of times I'll tell a patient, because I can look it up on the on the website, that you know, your cost of this medication, relatively speaking, is pretty low, and it may be worth your while to uh uh just go bypass the insurance company and pay for it out of pocket. Um but the medications have become more and more of a difficult time. Um uh we're now in an era of availability limitations. Uh not only in psychiatry, but in other aspects of medicine, medications may not be available at the pharmacy, which is almost like unheard of uh from 10 years ago, but now it's a real issue. And so uh people, especially people who have attention deficit disorder and are and are in stimulants, uh frequently they can't get it. And because it's a tightly controlled medication, if they call around to other pharmacies to see if they have it, the pharmacies are reluctant to give that information because of how tightly controlled it is. So um it's become a difficult uh uh obstacle course that uh uh clinicians have to have to run through as well as the patients themselves.

SPEAKER_01 15:52

So the other side of the coin of that isn't just that um the patient and the doctor have to go through these kinds of hoops as a result of uh complicated it gets with uh whether it be medication and insurance or it's the number of sessions or all of the forms that a psychologist or another health clinician has to fill out to send to get approval from the insurance companies. The result is there's a lot of mental health professionals who won't deal with insurance issues. And so it's all out of pocket. And so a selective process happens there where the clinician who no longer wants to deal with all of that and just charges fees out of pocket uh starts to differentiate the the whole profession so that the clinicians who remain in the insurance uh list are in in some respects clinically different than the clinicians who just take uh fee for service. And that leaves the patient with a kind of a hierarchy of quality, even because you you gain something and you lose something. And then on top of it, a lot of physicians, including psychiatrists, are choosing to not practice anymore. Think about how many we hear it all the time, the different specialties within medicine are saying, you know, it's too, it's too expensive to practice. I have to hire a whole staff just to handle insurance issues and so on and so forth. So it makes it really difficult for the patient to find good quality care, especially in the mental health field because of this issue.

SPEAKER_00 17:36

You know, the the other aspect of this, especially in in uh in medical specialties, um, internal medicine primary care provider as an example, is um with insurance management of reimbursement, uh physicians began to find themselves getting reimbursed at such a lower level that the only way to compensate is with volume. But when you compensate with volume of patients seen, practically you can't see as many patients as you'd like to. And and and a lot of good physicians in town, um, people who I've respected, uh began to get frustrated because they came out of medical school wanting to do the best job they could and provide good care to patients. But when you only have 10 minutes to sit with somebody and figure out what's wrong or see how the well they're doing on the particular treatment plan you put together, it's just not enough. Uh and it's not satisfying. And in fact, out of that frustration about 15, 20 years ago, uh came the uh MDVIP or concierge medicine concept, where physicians realize that instead of see these are internists of primary care doctors, instead of seeing 3,000 patients in my practice, which makes it very difficult to provide good quality care, um, if I limit it to 600, um, I can provide the kind of care I'd like to provide. But how do you do that? If you limit it to 600 uh and you are relying on Medicare or insurance reimbursement, uh the amount of money is going to be uh much less than what your overhead is. And so that's the that's how the concierge MDVIP model came to be with a fee, an annual fee that helps provide the balance so that the fee will take over uh in terms of income for what normally they would be getting. Um but not everybody can afford that. You know, the in various areas of of uh Palm Beach County, for example, I've heard that their the annual the annual fee for a concierge doctor is$10,000. I would say the average is probably two to three thousand dollars a year, but certainly that's not everything, not everybody can afford that. And it leaves individuals out uh out of uh the ability to get the kind of care they need. Um and then you're dealing with uh Medicaid, where there are limitations now on Medicaid coverage, and individuals who uh can't afford uh the kind of insurance that most people can uh have to rely on Medicaid, and Medicaid also can limit the number of clinicians they see. Um I don't know of any mental health professionals who provide uh um Medicaid coverage. I know that child psychiatrists will often be Medicaid providers, but it's it's uh the the insurance availability is a real issue, and and the development of concierge um medicine has even spread to specialties. There are neurologists and cardiologists now who are becoming concierge uh specialists, which limits the number of patients and really it it leads to a caste system of of care based upon affordability and what your income is. And so it's uh not an easy problem, and I don't know that there's an easy solution.

SPEAKER_01 20:47

So now that we've made everybody depressed about the state of our field, uh here's some good news. Um what their problem is. They may know, oh, my problem I'm having is anxiety, or my problem is I'm going through uh a divorce, or my problem is I uh I went through uh a traumatic episode, or my problem is uh my child, or what whatever. Usually people can identify in in some kind of layperson's way what their diagnosis might be in a general way. And so when you're looking for help, where do you go? Do you go to your insurance provider first and and pick out a name there, or do you uh look uh on the internet uh for people uh who provide uh special treatments, you know, or whether it be um psychotherapy or EMDR or um DBT, you know, these are all names that people somewhat familiar with. Or do you find a professional who uh is identified with and says they specialize in a particular type of problem? And in general, the best way to do this is not to find somebody based on what their procedure is, because unfortunately, a lot of times that procedure will then be applied to everybody. Find somebody whose main interest area and specialization is matched with the problem that you have. For example, if you have anxiety or have an anxiety disorder, look for somebody who specializes in anxiety disorder. Not specializes in everything, but anxiety. So, for instance, in that case, you would get in touch with uh something like Anxiety and Depression Association of America. All of the members of that, the providers that become members of that, have unique special interest and training in that area. And they can refer you to somebody in your geographic area who specializes in what you have. And if they if there is a mismatch once you talk to them, they can refer you to the right person, the right professional. If you're going through uh trauma, well, you can go on a website that deals with uh there's organizations and associations that deal with trauma, for instance. So that's a way to bypass some of the you know the poor quality of just going to your insurance company, and it bypasses the tendency to uh have somebody who, let's say, treats everybody with one particular method. It's a way to it's not the best way, it's not the only way, rather, but and but it is the best way to find a good clinician to match with what your need is, in spite of all of the issues with insurance and funding and fees and et cetera.

SPEAKER_00 24:03

Is the fact that um mental health issues and problems uh it it reflects a murky understanding of what's wrong. It's not as black and white as having chest pain or abdominal pain or high fever um or shortness of breath, which is uh black and white and easier to understand. Um so somebody with depression, for example, uh who feels terrible may look fine on the outside. So I think both you and I have devoted our our our careers to demystifying mental health and the nature of the problems. And and and I think uh what I've what I've heard from patients who've seen you is that uh you're an excellent educator. That uh the first step for both of us is to help the individual understand what's wrong uh and and how to approach it, and the fact that things can get better. Um and so uh making making mental health problems um uh easier to understand and not as mysterious and not as fraught with uh you know, God's light's not shining on me, or whatever uh misconceptions people have about anxiety or depression is our initial goal. And um it I think it helps a lot, as we've talked before in previous episodes, to develop the the concept of hope and the belief that things can be better in the future. Um and and to help people uh understand that that um we know what they're going through, even though we may not have experienced it ourselves, we've seen it enough times so that we have a sense of what it's like. And we also know that people get better. I tell this to people all the time. You know, I've I've seen individuals with uh panic disorders like yours or even worse than yours. And the good news is that there's a light at the end of the tunnel. Uh and and sometimes when you're when you're feeling terrible, you can't believe in what I'm saying. And I say, just trust me, when when you're better, you'll believe me. And that's all I can ask people to to agree with.

SPEAKER_01 26:03

Um my favorite thing is when I get to say to somebody, I told you so, because in the beginning they can't believe that they're gonna get better. And I say, Oh yeah, you will. And after X amount of time, and I just said it to somebody yesterday, had a grin on my face, and then I said, I told you so. So that's the best part of this.

SPEAKER_00 26:25

Yeah, I t I tell people all the time that the proof is of the pudding. You know, you I I can't promise you that you're gonna be better and that you're gonna believe me that you're gonna be better, but uh, when you begin to feel better, you'll believe me. And what's amazing about the disorders we treat is that uh I treat somebody who's had horrendous uh uh anxiety and depression and came through it and did fine and was well for a year or two and then had a relapse. When they got back into that relapse, they could not believe they could ever get better again. And even though I said, think back to how you were feeling when you were better, it doesn't register. And again, it gets back to you you're gonna have to wait until you're better and then you'll believe you're better.

SPEAKER_01 27:03

Right. It's uh it's a tough battle, but the good news is, and the reason why we're here and talking about all this is because we know people can get better and we love it. And we are at Two Shrinks in a Mike. Thank you for being here today. Bye-bye. The Two Shrinks in a Mike podcast is for informational and entertainment purposes only. The views expressed are those of the hosts and guests and do not constitute medical, legal, or professional advice.

SPEAKER_00 27:30

Please always consult a qualified healthcare provider before making any medical or wellness decisions. Our content is not a substitute for professional medical guidance, even though our mothers tell us we have the best advice possible.