Electronic Fall 2023 | Issue 56
A Multidimensional Reflection on Barriers to Psychiatric Care
By: Hibah Arshad, MS4 at Midwestern University- Chicago College of Osteopathic Medicine
While it is widely accepted that the clinical years in medical school are crucial for gaining first-hand exposure to medical management and patient interaction, an often overlooked advantage of rotations is the opportunity to more closely understand barriers to care and the many ways in which they can manifest. For example, while there are established protocols and medication regimens in the event of psychiatric decompensation, an individual's access to these interventions may be obstructed by insurance limitations and legal hurdles. Unfortunately, this example remains a present-day reality for many.
As I’ve navigated my own clinical rotations, I’ve witnessed numerous patients narrate this exact experience, describing a prolonged avoidance of the hospital due to concerns of high costs and extensive wait times. I’ve reflected on these experiences and also found valuable perspective from my siblings, who are each associated with the healthcare sector in different capacities. While my brother works in Behavioral Health Quality for managed care organizations, my sister is a third-year law student with a focus in health law. Through my siblings, and most of all, through the patients I’ve worked with on rotations, I’ve come to learn of common barriers to psychiatric care that persist in our current landscape.
In this article, I aim to briefly outline some of these barriers from three perspectives: medicine, business, and law. By better understanding the barriers to care in each of these contexts, we can more strategically design solutions, and ultimately meet the goal of delivering the highest quality care to patients.
Medicine: The Monitoring and Management
The national shortage of psychiatrists remains a primary challenge in meeting the needs of the general population. As the stigma towards mental health continues to be dismantled, mental health services are subsequently being recognized as an urgent need. The COVID-19 pandemic, in particular, shined a light on this need in all age groups. Despite this widely recognized demand, the number of available providers currently remains too low.
Secondly, many psychiatric conditions require long-term adherence to psychotropic medications, but compliance can be an obstacle. For example, in severe cases of major depressive disorder, symptoms may be extremely debilitating, making it difficult to consistently adhere to daily antidepressants. This challenge brings to light the utility of long-acting injectables as a treatment for certain conditions, but access to such injectables comes with its own unique set of obstacles.
Business: The System and Structure
Limited access to comprehensive health care remains an ongoing challenge for many in the United States. Like all other areas of medicine, this has significant implications on the delivery of psychiatric care. For uninsured Americans with psychiatric conditions, high out-of-pocket costs present an immediate barrier to medication and therapy. For patients that are insured, the number of treatments and interventions that can be covered by their insurance plan is occasionally restricted, leaving patients with inadequate management of their conditions.
In addition, many insurance plans have correlated provider networks. While these networks may offer structure and efficient coordination between “in-network” physicians, they may also limit patients from seeking treatment from other, more readily available psychiatrists who are “out-of-network”.
Law: The Rules and Regulations
Much of the existing legal framework surrounding psychiatric care is not standardized across the country, thus posing challenges for practitioners and patients alike. For example, if a patient is receiving psychiatric care, but has to relocate to a different state, their options may be altered based on the existing legislation in their new location. Subsequently, the patient may face an interruption in their care, thus placing them at risk for psychiatric decompensation.
During a recent psychiatry rotation, I noticed that the legal implications surrounding involuntary psychiatric hospitalization were a foundational, yet unexpected learning point. For example, if a patient may benefit from inpatient psychiatric hospitalization but is refusing this option altogether, a delicate interplay ensues between upholding patient autonomy while suggesting a treatment plan that ensures beneficence. This interplay is then also influenced by legislation, which has often been established on the basis of societal values, political conditions, and landmark court cases in the past.
In conclusion, these aforementioned medical, business-related, and legal challenges are evolving with time, and creative solutions will be necessary to effectively address them. By presenting the multidimensional nature of barriers to care, I hope to highlight the importance of an interdisciplinary approach going forward.