In November 2014, Mental Health America, a mental health advocacy group, published what it describes as its first annual report to provide a more complete picture of the mental health status in America. Titled “Parity or Disparity: The State of Mental Health in America 2015,” the report attempts to establish a baseline from which they can, in the future, document the successes and failures of both federal and state initiatives, and organize the data into 18 general categories relating to mental health status and access to mental health services.
The report was the focus of news stories across the country and in national outlets such as USA Today and The Wall Street Journal.
As expected, Vermont was ranked at various levels in different categories such as early intervention and network adequacy, but what struck me was the report ranked Vermont first in the United States for access to mental health care.
Such a finding is strongly at odds with my perspective of mental health care access in Vermont. What is going on here? Without going into painful detail, the authors of the report first acknowledge that finding data on mental health is “surprisingly difficult,” in part because there are many surveys that use different definitions for common terms and, in some instances, may or may not include homeless or institutionalized people.
The data used for the “access” score relied heavily on the availability and cost of insurance, access to special education, and “workforce availability.” Access to mental health services was defined very broadly, to include school-based services and mental health clinicians of all kinds.
Mental Health America worked hard to assemble a huge amount of data, and they tried to put it all together to create a few relatively simple rankings. They deserve enormous credit for bringing the issue of mental health care access to public attention. My review of their effort is critical, but there are important reasons for this.
Aggregate numbers can obscure details that are critical, and no survey has measured the essential question about access: Would I be able to get an appointment if I called to make an appointment?
It doesn’t matter if we are number one, or who is number one for that matter. The fact is we are not providing mental health and substance abuse services on the scale that is needed here in Vermont.
The aftermath of Tropical Storm Irene further weakened our ability to provide mental health care. But at the same time, the storm offered an opportunity to rethink, rebuild and improve care. And like all processes, the process of coming back from the storm involved compromise and the realities of working with federal and state agencies.
So where are we?
We have very long wait times for adult and child outpatient consultations. We have people waiting in hospital emergency departments every day for placement. Some of them, adults and youth, wait in emergency departments for many days, placing strains on staff and sheriff departments who are often employed as “sitters.”
Access to care for people with complicated illnesses is very limited, our opioid treatment programs are inadequate for the demand, and we do not have enough inpatient beds for people in the care and custody of the state.
It’s not a pretty picture.
But even with a new state hospital that is smaller than the one that was destroyed in the storm, mental health providers are finding new ways to try to extend thin resources. We have psychiatrists using telemedicine to work with patients and their families. We have new training opportunities for medical students within the UVM Health Network. And in the new world of population health management and accountable care organizations, with the increasing emphasis on the primary care setting, we have established a Medical Home Primary Psychiatry program.
None of this will be easy or happen quickly. And it won’t happen without stronger public support.
Although I am critical of the report’s methodologies, it has served to call attention to mental health care issues. But ranking or no ranking, we’re going to have to do better here in Vermont.
Bob Pierattini, MD, is the chair of Psychiatry at the University of Vermont Medical Center and professor and chair of the Department of Psychiatry at the Larner College of Medicine at UVM.