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Taking Depression Seriously: Breaking down barriers to care

In this second post in the Taking Depression Seriously series, Sophia Xiao and Randall Stafford examine barriers to accessing mental health care.

Since the 1970s, a range of effective treatment methods such as medications and therapies for depression have been developed. However, fewer than half of those affected by depression worldwide receive adequate care.

There are several reasons that care can be hard to access.

First, many mental health conditions still retain stigma. Milder symptoms of mental illness may be dismissed or ignored, and those with more severe conditions are often viewed as violent and volatile. These stigmas filter into the health care system as well, where many people with lived experience of mental illness have reported negative treatment by health care providers.

Second, in part due to this stigma, mental illness can often be hard to recognize because of the limited exposure people have to proper mental health education and awareness. Milder symptoms can be subtle at first and depression can be misjudged as "laziness" or just fatigue. Individuals themselves may struggle to accept that they need help.

Third, the cost of mental health services is still very high for those with and without insurance.

Finally, while the U.S. is facing a shortage of physicians, there is an even greater shortage of mental health professionals. All of these factors can make access to treatment difficult for those who desperately need it.

However, recent legislation -- including the federal Affordable Care Act and the federal Mental Health Parity and the Addiction Equity Act of 2008 -- aims to address this issue. Through this legislation, federal or private health plans must treat mental health and substance use disorders the same as all other conditions. For example, if your insurance plan provides unlimited clinic visits for a chronic disease like diabetes, they must also offer unlimited visits for conditions such as depression or schizophrenia.

These two policies are still relatively young, though, and some plans have been slow to comply.

"Although we have had these two pieces of legislation in place for years, research, records of complaints, and lawsuits since 2008 have shown that not all plans follow the rules. Health plans are still coming on board with these regulations," says Heather Gotham, PhD, a Stanford clinical associate professor of psychiatry and behavioral sciences.

If you think your plan is violating these requirements, talk with your plan and file a written formal appeal if other methods prove unsuccessful. Even if your plan is following these regulations, there are still other potential barriers to access.

For example, Ms. C, the former salon owner introduced in our last post, received coverage through her county health insurance plan, but the number of therapists who accepted her insurance was limited, and she was unable to find one that she felt comfortable working with.

For Ms. C and others struggling to find affordable traditional therapy, there are other lower-cost alternatives that may help.

Some therapists provide free or reduced-cost individual and group therapy. Some universities have counseling centers for people in the community that are typically staffed by graduate students. Local health departments often provide crisis care services over the phone or even in person if necessary. Additional services can also help connect individuals to appropriate care in the area. If insurance is provided by an employer, it is useful to ask human resources what mental health options exist. Primary care physicians are also great resources for referral to psychiatry or talk therapy, and they can also diagnose and prescribe some mental health medications themselves.

Lastly, the internet can be a useful place to research different therapists, their specialties, and their backgrounds before booking an appointment. Sites like Psychology Today and GoodTherapy provide a directory of therapists based on zip code or city, complete with the contact information for and descriptions of each provider. Searching for "therapists near me" in Google will also usually generate a map of provider offices in your area with client reviews listed for each. This may increase the chances that the therapist you pick is the right fit. However, like all other information gathered from the internet, it is important to recognize that while trustworthy sources exist, there are also many opinions not backed by facts or research.

Once you gain access to care, the most effective treatments include talk therapy and medications as well as physical activity and other lifestyle strategies. Generally, health practitioners encourage all three to be used together for maximum effectiveness. Over the course of the next several blog posts, we will go deeper into each of these treatments.

This is second in a series of blog posts, Taking Depression Seriously, that aims to help patients and family members better understand depression as a chronic disease and more successfully navigate the health care system. The next post will introduce the types of treatment available for depression.

Sophia Xiao is a master's degree student in Community Health and Prevention Research at Stanford who studies barriers to health care and the role of public health education in improving access to care. Stanford professor and primary care physician Randall Stafford, MD, PhD, studies strategies to improve chronic disease treatment, including increasing the role of patients in their health care.

Photo by Johannes Plenio

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