Stretching To Meet Mental Health Needs In Michigan
A new study shows more Michigan residents are depressed than those in other states, and mental health care workers are using telephone and video conferencing to reach out to patients in areas without psychiatric services.
Already overburdened with high case loads, mental health professionals statewide are expecting increased demand under the federal Affordable Care Act, which requires insurance companies to provide mental health coverage that is equal to what’s provided for physical-health conditions. Health advocates worry that the load will keep some patients from getting mental health care, despite their new benefits.
Efforts are under way to provide more psychiatric training to family practice physicians, pediatricians, physician assistants and nurse practitioners who increasingly are prescribing psychiatric medications — often for patients with immensely complex cases. And telemedicine, such as patient evaluations conducted through video-conferencing, is playing an increasing role in the delivery of mental health care.
“We’re not trained specifically in psychiatric care,” said Kim Michaels, a nurse practitioner with K-Town Youth Care in Kingsley, just south of Traverse City. The Grand Traverse County Health Department program treats patients that are 10 to 21 years old.
“We need psychiatrists to help us with the more complicated or riskier medications. The patients are becoming more and more complex, and it’s getting to the point where we need help.”
In a recent study by the University of Michigan Center for Healthcare Research and Transformation, 1 in 5 Michiganians surveyed reported being diagnosed with depression at some point in their lives — 20% in the state, compared with the national average of 18%. Asked if they’d ever been diagnosed with depression, an anxiety disorder or both, 26% answered “yes.” The percentages were even higher among those with Medicaid or without insurance.
“Economic stress, poor access to healthcare, unemployment, are all risk factors (for depression) and Michigan unfortunately is saddled with those burdens more than other states, so I wouldn’t be surprised that it’s at the higher tier among states (for depression),” said Gregory Dalack, M.D., chair of the University of Michigan Department of Psychiatry, which is beefing up support for primary care clinicians through pilot projects offering psychiatric consultations and evaluations via telephone and services like Skype.
State Has Shortages
Michigan is short on both outpatient mental health services and inpatient psychiatric beds. It’s not uncommon for physicians to send patients a hundred miles away or further for inpatient treatment.
“When I have somebody that’s suicidal, they go primarily to Mount Pleasant or Grand Rapids,” said Cindy Smith, M.D., a pediatrician who practices in Traverse City and Kalkaska.
More needs to be done to expand outpatient services, which were never expanded to the extent needed to replace psychiatric hospitals that were closed down in the ’80s, said Marianne Udow-Phillips, director of the Center for Heathcare Research and Transformation. At the same time, too few medical students are choosing to go into psychiatry, which pays less than medical specialties like dermatology or surgery.
“We clearly have a mismatch in demand and capacity,” she said. “We need more psychiatrists coming out of the pipeline.”
Michaels is assisted by psychiatrists with the Michigan Child Collaborative Care program (MC3), a University of Michigan program that connects her with psychiatrists via phone and teleconferencing.
Sheila Marcus, M.D., director of child and adolescent psychiatry at U-M, leads a team of four psychiatrists who answer calls from primary care physicians in need of advice. If needed, they evaluate patients via video-conferencing.
Commercial telemedicine companies also are increasing access to psychiatrists and other medical specialists. Teladoc, which claims to be the nation’s largest telemedicine provider, says more than 100,000 Michiganians subscribe to its service, which in most cases is paid for by their employers.
The U-M program has patient care coordinators in parts of the state that don’t have enough psychiatrists. The program’s psychiatrists carry pagers so that coordinators can reach them by phone if a local physician is in need of advice.
'Needs are overwhelming'
Jennette Gaggino, M.D. is one of 33 Kalamazoo County pediatricians participating in the U-M program. Physicians in Kalamazoo have received more than 250 phone consultations from MC3 psychiatrists over the past 18 months, she said. The program is funded by a combination of grants, so there is no charge to patients or physicians.
“(Primary care physicians) need much more support as the demands and needs are overwhelming,” Gaggino said. “The availability of just-in-time help is amazingly helpful.
“Not only are we able to review difficult cases, but we gain confidence in assessing and treating more difficult cases down the road. The reality is that there are not now, nor will there be in my lifetime, enough psychiatrists to care for all these children.”
Finding help, advice
Suzanne Coleman, a psychotherapist from Kalamazoo, is guardian for two grandchildren with psychiatric issues. Her daughter is unable to care for them due to psychiatric problems of her own. Coleman said U-M’s program has provided psychiatrists for her patients, and even her own grandchildren.
Coleman’s grandson, 11-year-old Ben, has attention deficit hyperactivity disorder but had side effects from traditional ADHD medicines. So Gaggino, the family’s pediatrician, got advice from an MC3 psychiatrist.
“One medication kept him from eating, and one made him hear voices,” Coleman said. “Dr. Gaggino consulted with a U-M psychiatrist, and they steered him to a medicine (that has been) very helpful for him.
“As a professional, I’m constantly needing psychiatric care for my clients, and ... the patients are left hanging many times. This has really been a lifeline.”
Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.
