For psychiatric services, wait for the beep

Feb 25 2009

Two-thirds of patients referred for psychiatric services following an emergency room visit are likely to reach only an answering machine when they call for help, compared to about 20 percent of patients calling medical clinics with physical symptoms.

Only 10 percent of all calls to mental health clinics in nine U.S. cities resulted in an appointment scheduled within two weeks, according to a new University of Pennsylvania School of Medicine study published in Annals of Emergency Medicine.

"Our results indicate that even the most motivated patients will have difficulty obtaining timely appointments and pursuing treatment for mental health complaints, despite prior studies that fault patient non-compliance for poor follow-up rates for psychiatric conditions," says lead author Karin V. Rhodes, MD, assistant professor of Emergency Medicine and Director of Penn's Division of Emergency Care Policy Research. "As we approach health care reform, we need to redouble our efforts toward improving mental health parity and design our health systems in ways that do not discourage people from getting important treatment."

Since emergency departments are safety net providers for uninsured and underinsured patients, they are frequently the location where mental illnesses like depression - which affects 17 percent of all Americans at some point in their lives -- are first identified. But because emergency departments are designed to treat acute illnesses and injuries and are not equipped to evaluate and care for non-emergent mental health conditions, these patients are most often referred for psychiatric care in the community. The Penn study found, however, that mental health patients encounter many roadblocks - only voicemail on the other end of the phone, or unreasonably long waits for an appointment - when trying to access that care.

The study findings showed that even private insurance did not ensure access: If and when a caller was able to reach clinic personnel, only 67 percent of privately-insured and 33 percent of Medicaid patients were able to make an appointment.

The Penn researchers used an "audit study" design that has previously been used to measure discrimination in other markets such as housing and employment. In the Penn study, trained research assistants posed as patients calling to obtain an appointment after being diagnosed with depression in a local emergency room the night before and referred for urgent follow-up to the number being called.

Results from calls to a random sample of mental health clinics in nine U.S. cities revealed that callers were able to reach appointment personnel only 31 percent of the time, compared with 78 percent of calls to medical clinics for physical complaints including pneumonia, severe high blood pressure and a suspected ectopic pregnancy. The "depressed" callers also had to make more calls overall in order to get services; fifteen percent of successful mental health callers had to make five or more attempts before reaching clinic personnel, compared to three percent of callers with medical complaints.

When callers who reached appointment personnel could not get an appointment, due either to insurance or capacity constraints, roughly 75 percent received information about alternative providers, but only half of them were given a name and contact information for that provider. About 14 percent were referred back to an emergency department. Among callers who secured appointments, 61 percent had to be scheduled for during regular business hours because clinics did not offer night or weekend hours - which the authors say may pose hurdles to employed persons who seek mental health treatment.

While it is relatively inexpensive to combine resources to outsource appointment scheduling, it is likely that mental health clinics are both short staffed and lack the financial incentives required to reduce barriers to timely appointments. The researchers say this is a troubling trend, as evidence suggests that making it easier to access depression care after an ED visit might be lifesaving.

"Our results would suggest that, for patients who are not already engaged with a mental health provider, 'usual care' after an ED visit for depression involves leaving a message on an answering machine," Rhodes says. "More work is needed to assess whether depressed patients, who by definition are likely feeling hopeless and low in energy, interpret these access barriers as further evidence of their inability to function or as a rejection, and the extent to which these access barriers exacerbate depression and/or lead to suicidal thoughts."