Access to mental health care is so difficult in San Franciscom that even on the cusp of crises, residents like Greta Christina have been asked to wait weeks, even months, for a doctor’s appointment.
“It’s gotten worse and worse,” said Christina, 59, who sees a therapist through Kaiser Permanente. “I couldn’t get an appointment until every three weeks, then it became every four weeks. And now, I’m lucky if we can see each other every six or eight weeks even.”
Long wait times for mental health care can often be detrimental to recovery for people experiencing a wide range of illness, from depression and anxiety to schizophrenia and drug use disorders — all of which have been exacerbated by the pandemic.
“This is the worst depression I’ve experienced; it’s serious chronic debilitating depression and it has interfered with my ability to work and manage everyday life,” said Christina, who lives in the Mission District. “I really fricken’ need to be in therapy.”
The issue is prevalent across health care providers in California, where state law requires insurers to provide mental health assessments for patients within 10 weekdays of any request. But California stops short of requiring timely follow-up and subsequent care after that first appointment.
“After they are seen initially, return appointments are between 7-12 weeks away,” said Brandi Plumley, a licensed marriage and family therapist who works for Kaiser out of Vallejo. “It’s pretty horrific, to be honest with you. If you wait too long between appointments, the progress you made can get washed away.”
Legislation now sitting on Gov. Gavin Newsom’s desk, Senate Bill 221, would create new standards for follow-up appointments within 10 business days, unless a clinician determines a longer wait is safe and necessary.
State Sen. Scott Wiener (D-San Francisco) first proposed the bill in January. Since then it has been approved unanimously by the Assembly and passed 34-1 in the Senate.
“This year, in talking to patients, we really learned that a lot of people have a quick first appointment but then have to wait months for their second and subsequent appointments and that really undermines their ability to get better,” Wiener said. “It’s been a real focus to make sure that people who actually have insurance can get mental health treatment.”
If signed by Newsom, the new policy would also apply to treatment related to drug use disorders, which have skyrocketed in San Francisco during the pandemic.
Since March 2020, overdose deaths in The City have surpassed COVID-19 deaths by a margin of nearly three to one. There have been more than 450 accidental overdoses in San Francisco in 2021 alone, according to the Medical Examiner’s office.
“Delaying mental health and substance use disorder treatment can be as life-threatening as delaying chemotherapy or dialysis,” said Sal Rosselli, president of the National Union of Healthcare Workers, which represents more than 4,000 psychologists, therapists and psychiatric nurses in California. “Our members are confronting an unprecedented surge in demand for mental health care.”
Timely access to mental health treatment was the top concern among respondents of a survey from the California Health Care Foundation released just a month before COVID sent the state into a lockdown to prevent community spread of the virus.
Numerous reports and data sources show that the global pandemic correlated with a spike in mental illness. One national survey by the U.S. Census Bureau and National Center for Health Statistics found that rates of depression and anxiety have tripled over the last year.
The problem has been particularly acute among young people, with nearly a quarter of people ages 18 to 24 saying they experienced suicidal thoughts in the past 30 days, according to the Centers for Disease and Control.
“One of the ironies of this is I really like Kaiser, generally,” said Christina, who was recently diagnosed with cancer. “Their breast cancer team has been a well-oiled machine. I’ve gotten everything I’ve needed and more — except for mental health. And having depression is making it harder for me to do the things I need to do to manage this cancer.”
Christina considers herself lucky in that she has a doctor she trusts and knows how to engage with the health care system. But for individuals who have had to endure discrimination or mistrust the medical field for a variety of reasons, providing timely subsequent care is essential for keeping vulnerable patients attached to the care they need.
“When I was in practice, getting clients, particularly those with severe mental illness and getting them to go to that first session can be a labor of love,” said Dr. Le Ondra Clark Harvey, CEO of the California Council of Community Behavioral Health Agencies. “Imagine getting someone finally there, and then say we can’t see you again for many days. People never came back when I was in practice.”
Clark Harvey believes that SB 221 will set up some necessary safeguards to prevent more patients from falling out of care. But there are other pieces to this puzzle.
Part of the problem is that therapists like Plumley already have large, often unsustainable caseloads. Understaffing is a huge contributor to the long wait times that patients must experience.
“The pandemic has exacerbated the need for mental health care and stretched the caregivers who provide it, and we empathize with every provider and patient whose experience has been made harder as a result,” said Yener Balan, vice president of Behavioral Health and Specialty Services, Kaiser Permanente in Northern California.
“Our concerns about the existing shortage of mental health professionals — and the need to address this as an obstacle to increasing access to care — remain, and extend well beyond the challenges of the SB 221 legislation,” said Balan.
The evidence is mixed on just how dire the shortage of mental health workers is, however, according to a 2019 report from the California Legislative Analyst’s Office. The report notes that the number of California graduates with professional mental health degrees has infact increased significantly over the last decade. The Bay Area has nearly 50% more mental health professionals than the state average, according to the report. Many work in private practice.
If the current trajectory of growth among health care workers is not sustained, there could be a statewide shortage in mental health care workers in the future, the report states.
“They say it’s hard to hire. And I’m not sure quite how true that is. If I decided to find therapy out of pocket, I would be able to do so,” said Christina. “What I want is really simple: I want Kaiser to hire more therapists and pay enough money to attract more therapists. Period.”
Kaiser has added around 600 therapists in California since 2016, according to Balan, and is currently hiring for 300 clinical positions. The health care giant is also putting $30 million into a statewide initiative to train new mental health care workers.
In the meantime, for patients like Christina, timely subsequent care can make or break recovery and even impact long-term illness.
“There is a lot of research that long-term depression can have long-term damage, and I already am experiencing some memory loss,” she said. “I want to see my therapist and I want to get better. I am just desperate to get actual therapy as often as I need it.”