A report by the Connecticut Behavioral Health Partnership found that women were underrepresented in Medicaid-funded behavioral health services in the state even though research shows that women suffer from the most commonly diagnosed mental health disorders more frequently than men.

Racial and ethnic disparities, while still considerable, are decreasing in some physical illnesses. “But in mental health care, in the last 10 years, we see those disparities widening,” said Megan Smith, associate professor in the Departments of Psychiatry and in the Child Study Center in the Yale School of Medicine, who runs the Mental health Outreach for MotherS (MOMS) Partnership^®, a program that offers mental health services to “overburdened and under-resourced mothers.”

In this podcast, sponsored by ConnectiCare, Colleen Shaddox discusses the hurdles to mental health care and the programs breaking barriers to care with Yale’s Megan Smith and UConn Health’s Dr. Sarah Nguyen.

Lack of insurance coverage, the cost of treatment, a shortage of qualified clinicians, stigma and even fear of losing custody of their children can keep women from seeking help, Smith said. Blacks and Hispanics are more likely to report psychological distress than non-Hispanic whites, and the rates increase dramatically for minorities who live in poverty, according to the Centers for Disease Control and Prevention. But white women are using mental health services at more than twice the rate of black or Hispanic women, data from the federal Substance Abuse and Mental Health Services Administration show.

“Unfortunately, lack of health insurance is often the biggest barrier to receiving care for depression. And with the lack of insurance there are financial barriers that come into play,” said Dr. Sarah Nguyen, a psychiatrist and faculty member at the University of Connecticut School of Medicine.

Megan Smith, associate professor in the Departments of Psychiatry and Child Study Center, Yale School of Medicine.

More than 42 percent of adults who do not get needed mental health treatment said they cannot afford it, according to the National Survey on Drug Use and Health. Medicaid does not reimburse clinicians for the full cost of mental health treatment, creating a shortage of providers who accept Medicaid. A 2015 study found that Connecticut clinicians experience a $27 million annual loss versus standard fees when providing mental health care under Medicaid.

There is also a shortage of clinicians who are minorities. “I think it goes back to increasing the human capital in the mental health field,” Smith said. “What I mean by that is really increasing the training and the availability of providers who are of racial and ethnic minority background themselves, and of providers who accept Medicaid and sliding scale, and, particularly, providers who are using evidence-based treatments. We know we have to be concerned about the quality of care, and so we want to, of course, lift up the quality of care that everyone receives.”

And then there is stigma, which is blamed for keeping people out of treatment regardless of background. Research shows that pressure to be “a strong woman” and a reliance on faith communities and other sources outside of health care providers discourage black women from seeking depression treatment.

Women who use the MOMs program often do not even use the word depression. “Stress is actually the way that many mothers we talk to describe depression,” Smith said. “So, mothers will talk about stress and really mean anxiety, trauma, addiction, depression.”

Women can access MOMs services at places like the laundromat. They can even get therapy at the local Stop & Shop. “The feedback we have from mothers on that is excellent,” Smith said. “They really like receiving care there. They feel safe. They feel secure, and it really feels like part of the community.”

One day a week Nguyen practices in a primary care center and sees patients she says would never have come to her psychiatry office to begin therapy. “Once I’ve established a rapport and a relationship with [patients] they’re more open to seeing me in other clinics,” she said.

Being in the primary care clinic is a particularly good way to get immigrant women into treatment, Nguyen added, because immigrants with depression are more likely to come in complaining of a physical problem like a stomach ache.

Tina Encarnacion/UConn Health Photo.

Dr. Sarah Nguyen, a psychiatrist at UConn Health.

Fear surrounding immigration status keeps some people from seeking depression treatment and so does fear of losing custody of a child. Smith stressed that mothers around the country do face child welfare systems that can penalize them for mental illness, but she offered assurances that Connecticut is different. “I think what’s helpful in Connecticut is that our child welfare system is informed about brain science and child development and knows the importance of promoting that dyadic relationship between mothers and children,” she said.

Though financial barriers can keep women out of care, Dr. F. Carl Mueller, associate chair of psychiatry at Stamford Health, urges women not to assume that care is out of reach. “There’s a lot you can do,” he said. “This is not necessarily an expensive proposition. There are short-term treatments that get people out of the darkest places.” He added that treating depression can be essential to avoid lost wages and even job loss. “Depression kills income,” he said.

There is a 50 percent increase in employment among women who get mental health treatment through MOMs, Smith said, citing “a real link between mental health and wealth.”

This is Part 2 of C-HIT’s series on women and depression, sponsored by ConnectiCare. Part 1 is available here.

Poor access to care leads to undiagnosed or misdiagnosed mental illness in children and adolescents, an increase in use of emergency rooms for psychiatric issues, and is a risk factor for severe mental illness, substance abuse, failure in school, and entering the juvenile justice system.

National studies show that about 1 in 5 children and teens have mental illness, but only one quarter of them receive services. “That leaves about 125,000 children without mental health care in Connecticut,” said Susan Kelley, director of the Alliance for Children’s Mental Health.

iStock Photo.

About 125,000 adolescents in Connecticut are not receiving mental health services.

Some say that estimate is low, partly because it doesn’t capture mental illness misdiagnosed as behavioral problems. “I think that’s a very optimistic figure,” said Eliot Brenner, PhD, president and CEO of the Child Guidance Center of Southern Connecticut. “It’s probably closer to 80 percent who need mental health treatment that aren’t getting it,” he said.

Advocates point to low reimbursements by health insurers, which discourage psychologists and other mental health providers from joining networks, and lead to high out-of-pocket costs for families. In Connecticut, poor access can also be traced to a lack of coordinated services for children and families in need.

Low Insurance Participation

Many qualified mental health providers do not participate in insurance networks in Connecticut.

In fact, state legislators are pushing for the passage of Senate Bill 384 that requires insurance companies to offer a larger network of mental health providers and require mental health screenings at all annual physical exams.

A study in JAMA Psychiatry found that a little over half of psychiatrists nationally take insurance, compared with close to 90 percent of physicians in other medical specialties. One reason is low reimbursement rates, according to a report by the National Alliance on Mental Illness (NAMI).  “For the amount of time that’s needed to spend with a patient, the private insurers don’t pay enough for many clinicians to accept insurance,” Brenner said.

According to the NAMI survey, 34 percent of people with private insurance reported difficulty finding a mental health therapist in network.  Of those who had received residential mental health care, 27 percent reported trouble finding an appropriate facility, either in or out of network, and 24 percent had to go out of network, racking up large out-of-pocket costs. “There are hard-working middle-class families who do pretty well, but they can’t afford certain mental health services, especially residential care,” Kelley said.

Evelyn Cope of Stratford, faced many obstacles when seeking care for her daughter, who began having behavioral issues in third grade. Though Cope brought her daughter to mental health specialists in her private insurance network, she was not happy with the quality of the care.  Her daughter was misdiagnosed with attention deficit hyperactivity disorder (ADHD), bipolar disorder, and disruptive mood dysregulation disorder.

“They talk to you for one minute and just give you medication,” Cope said. When her daughter became more difficult and combative, Cope tried to find a comprehensive program for her, but she was told there was a long wait list because she had private insurance. When she finally got on Husky after a divorce and had access to programs, they would only last a few weeks or months, but her daughter needed more continuous care.  “My first question was always, ‘How long is the program?’ ” she said.

Lack Of Coordinated Care

Most experts agree that comprehensive services, which not only provide therapy or medication to a child, but also offer support to the family, are the most effective. Yet few such programs exist. “If you have a child dealing with a behavioral health problem, it’s not a child’s problem, it’s a family system problem,” said Leanne McEvoy, executive director of Empowering Children and Families (ECF), a nonprofit organization in Monroe that offers comprehensive services. Programs need to address a range of issues, including parenting and family dynamics, educational issues, and health and cultural issues. “In the public and private sector there is no coordinated care,” McEvoy said.

State budget cuts have made things worse, with cutbacks eating into some programs for children, particularly higher levels of care, such as inpatient services and day treatment programs for the most seriously ill. That puts increasing pressure on community-based organizations.  “Kids who need more intensive programs are being treated with less intensive programs, which is not adequate,” Brenner said.

School-based programs offer mental health care, but it is not enough to meet the demand. According to the 2017 Connecticut Children’s Behavioral Health Plan: Progress Report, demand for mental health services in schools is greater than provider hours, and budget cuts have worsened the situation.

“The problem is that we don’t have a coordinated mental health system that asks ‘What are the mental health needs of children in the state, and what funds and programs do we have to meet those needs,’” Kelley said. Public Act 13-178 Children’s Behavioral Health Plan was mandated to address this issue in 2014, in response to the Sandy Hook school shooting. While some progress has been made, advocates say there has been little success in coordinating children’s mental health services.

Behavioral vs. Mental Health

Like Cope’s daughter, many children, especially African American and Hispanic children, are diagnosed with behavioral aggressive conduct issues and ADHD rather than mood disorders. “I’ve heard from many parents: As soon as my child hits the third grade, it becomes a behavioral issue—the way it’s addressed—not a mental health issue,” said Tirzah Kemp, program manager at New Haven’s Clifford Beers Clinic, which treats children who have experienced trauma.

“They are sitting with depression or anxiety and if it’s being labeled as bad behavior and not being addressed as a mental health issue, it is a pipeline to delinquent behavior and the juvenile justice system,” Kemp said.

Cope’s daughter was finally diagnosed correctly by a psychiatrist with the ECF program. She had a sensory processing disorder. He prescribed an effective medication and therapy, and the program provided a big-sister type mentor as well as support and therapy for Cope. ECF also sends a team to the school with Cope for parent teacher meetings. “This program is what saved my daughter’s life and my life,” Cope said. “I was getting sick, it was so much stress on me.”