The everyday grind of law school was beginning to wear on Andy Page.
The Omaha native was closing in on his law degree at the University of Nebraska-Lincoln when he began to feel overwhelmed. He was stressed and had trouble focusing. On top of his studies, Page volunteered at an immigration law clinic and worked part time, a combined commitment of 60-70 hours a week.
Page had experienced similar feelings as a first-year law student. Back then, he tried to reach out for counseling help.
“Now that I’m 25, I’ve just started to think, do I want to feel like this for the rest of my life?” he said.
So this year, Page went to student services at UNL looking for a counselor but was told it would take at least three weeks to get in for an in-take appointment and three more to see someone.
Then he turned to Google. He searched for mental health professionals near him and checked in with four different clinics in Lincoln. He heard the same refrain: Either the clinics weren’t accepting new patients, had long waitlists or didn’t take Page’s insurance.
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“They would turn you away or say, ‘We can fit you in, but it can be four weeks,'” he said. “Well, four weeks down the road isn’t really going to help.”
Page is among many in Nebraska who are struggling to access mental health care amid a lack of providers and unprecedented demand for services — from inpatient stays to outpatient counseling visits.
“I started to have to kind of take a lot of it on myself,” he said. “Instead of doing it with a therapist, it’s doing it through an app.”
Nearly 1 in 5 Nebraskans has a diagnosable mental health or substance use disorder, a number some experts say may grow in the wake of the COVID-19 pandemic and the illness, isolation, grief and trauma it brought with it. Neurological problems linked to the coronavirus and “long COVID” have also raised concerns.
At Bryan Health, online behavioral health screenings were up 17% in 2021 compared to three years ago. Meanwhile, CenterPointe, which offers outpatient and inpatient addiction and mental health treatment programs in Lincoln and Omaha, served nearly 4,270 people in the 2020-21 fiscal year, a 26% increase from 2019-20.
Nationally, the Centers for Disease Control and Prevention disclosed the percentage of adults reporting symptoms of anxiety or depression increased from 36.4% to 41.5% from August 2020 to February 2021. The percentage of those reporting unmet mental health care grew from 9% to 11.7%.
And a 2021 report from the Harvard Graduate School of Education suggested that as many as 1 in 3 Americans and over 60% of young adults faced “serious loneliness” over the past two years.
“It is the bigger pandemic,” CenterPointe CEO Topher Hansen said. “It’s a little quieter, but it’s huge out there, and it’s not necessarily resolving in the same way. You can’t get a vaccine for that.”
The services required to meet a growing influx of people with mental health issues are lagging behind as many providers struggle to hire and retain staff.
CenterPointe offers a variety of mental health crisis services, many of which are tailored toward low-income or homeless individuals — 62% of the people they served in 2021 made less than $1,000 a year.
But due to workforce shortages, the agency is at 80% of typical staffing levels. Twenty beds at a new short-term residential program in Omaha cannot be filled because of the lack of therapists, Hansen said. Anywhere from 80-120 people are on a waitlist for that program alone.
“It’s really been frustrating when you see so many people in need,” he said. “We’ve never seen a situation like this before.”
While the number of behavioral health providers has increased in the past decade, Nebraska’s supply of workers is struggling to meet demand, especially in rural areas.
The number of psychiatric prescribers in the state did increase by 32% from 2010 to 2020, according to a report from the Behavioral Health Education Center of Nebraska. The number of psychologists and mental health therapists increased by even more — growing 39%.
But compared to national workforce figures, Nebraska falls woefully behind. In the United States, there are roughly 14 psychiatrists per 100,000 residents compared to around eight per 100,000 Nebraskans, according to the University of Nebraska Medical Center report. The situation is dire in rural parts of the state, where there are just three psychiatrists for every 100,000 people.
In total, 88 of Nebraska’s 93 counties meet the federal threshold to be considered mental health professional shortage areas. In 29 counties, there is no behavioral health provider at all.
When it comes to looking after the state’s children, pediatricians have often had to bear the burden amid a lack of psychiatrists specializing in children’s mental health. While the rates of child psychiatrists have grown — reaching 9.75 per 100,000 children nationally in 2016 — Nebraska is sitting at eight per 100,000 kids.
“We’re fortunate here in the Lincoln area that there are more providers for people to try to access and get into. Whereas I talked to some of my colleagues in rural areas, that only have a couple of providers to cover multiple communities,” said Dave Miers, director of behavioral health services at Bryan Medical Center. “… It’s just really difficult for them to keep up with the demand.”
Bryan operates a mental health emergency room at its West Campus in Lincoln — one of the first in the nation at the time it opened — as well as an outpatient counseling center. Last year was a record year for patients seeking emergency mental health services, Miers said, but expansions before the pandemic have allowed the hospital to absorb the increased demand.
He said Bryan hasn’t had some of the difficulties other providers have experienced retaining staff and credits the hospital system’s strong retention program.
But not everyone has been as lucky.
Over the past two years, many in the mental health field have reevaluated their career choices, CenterPointe’s Hansen said. Some staff retired or moved or simply left for higher-paying jobs or remote work elsewhere. CenterPointe hiked its average pay by 17%, but it’s still not enough to keep up with wage increases elsewhere, Hansen added.
“It’s like the floor of the whole thing raised up,” he said.
The difficulties accessing care combined with increased caseloads have created a “cultural crisis point” in mental health availability, said psychologist Camie Nitzel. At Nitzel’s counseling practice, Kindred Psychology in southwest Lincoln, there were nearly 180 people on a waiting list at the end of April.
Nitzel’s practice helps refer those on the waitlist to other community providers and last week its client care coordinator began contacting those who were still waiting.
It’s been “very rare” for people to report finding another available provider, Nitzel said. For those in luck, “it’s taken over a month of active searching to find an opening.”
The staff at Kindred are all taking on bigger caseloads to meet the demand, but at a cost.
“You can only work full time plus an extra 30 hours a week for so long before your own soul starts to feel scorched,” she said.
For those from underrepresented backgrounds, finding a counselor or therapist that looks like you or shares your lived experience is even harder.
At Nitzel’s practice, many of the clients are in the LGBTQ community. But because of the long waits, Nitzel says many people have gone to anybody with an opening, regardless of specialty or personal preference.
Marty Ramirez counseled students at UNL’s Counseling and Psychological Services for 38 years and also advised the university’s Latino student group. He said the pandemic not only elevated the conversation around mental health but exposed systemic health inequities and the need for greater cultural awareness among mental health workers.
“COVID is like throwing a rock in a pond, and all those waves from the pond is a different phenomenon,” he said.
Minorities were hit disproportionately hard during the pandemic and now the long-term impacts on mental health are beginning to emerge. But there’s a lack of diverse therapists to deal with the crisis, he says.
One silver lining from the pandemic was the rapid expansion of telehealth, which allowed for greater ease of access for patients and providers alike.
Connie Nelson, a psychiatric nurse practitioner who helps clients manage their medication, saw the first patient at her newly opened private practice in Lincoln on March 2.
Two weeks later, she was seeing patients mostly over a computer screen.
“It’s already challenging enough to open a practice, but then there’s a whole other component when you start doing telehealth,” Nelson said.
Slowly, the number of in-person visits began to tick back up, and now only roughly a third of Nelson’s appointments are conducted virtually.
When federal regulators said Medicare would cover telehealth visits at the pandemic’s onset, many private insurers followed suit. Last year, Nebraska lawmakers embedded telehealth coverage into state law, requiring insurers to reimburse mental health telehealth services at the same rate as a comparable in-person treatment.
But finding a therapist that even accepts your insurance to begin with can be challenging, said Sue Outson, one of the operators of Lincoln Wellness Group, a network of independent counseling practices, including Nelson’s.
At one end, it’s difficult for many practices, especially smaller ones, to keep up with the vast number of insurers, Outson said. On the other, practices will simply refuse to carry an insurer because they don’t reimburse well.
Therapists and counselors also typically set their own schedules and the caseloads they’re comfortable handling, meaning new clients hoping to find an opening may be out of luck. Many past clients have decided to start seeing their therapist again during the pandemic, further complicating the caseload crises.
“There is this kind of mechanism that we’ve all had, which is when somebody resurfaces you try to build them into your schedule,” Outson said.
Eyes on children
The mental health impacts of the pandemic on children and young adults have been particularly worrying.
At Project Harmony, a child advocacy center in Omaha, therapy referrals for students experiencing depression and anxiety have increased.
Last year, the center, which works with children who have experienced abuse, scheduled over 8,300 therapy sessions through its Connections program, in which therapists meet with students primarily at school. By March of this year, Project Harmony had already reached nearly half that total.
“We know that school was a stabilizing factor for kids. There was a lot of structure with that,” said Joanna Halbur, director of mental health services at Project Harmony. “When kids went home (in March 2020), those went away.”
The wait to see a therapist through Project Harmony extended as long as 44 days back in December but has leveled off as the pandemic has subsided.
A Lincoln woman who asked that her name not be used said her 15-year-old, who has autism, anxiety and ADHD, has been on a waitlist since last year to find an at-home therapist.
Navigating mental health care has always been difficult — and costly — she said. But now, the demand has changed.
“There’s such a significant need in Lincoln,” she said.
In recent years, the elevation of mental health in the public discourse has in part dispelled some of the stigma of seeking help. Athletes, actors, musicians and even royalty have been more open about their own battles with mental illness.
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But the average delay between the onset of symptoms and diagnosis is still long — 11 years, according to the National Alliance on Mental Illness.
And unlike when people experience physical pain or illness, many simply don’t know where to start when it comes to seeking mental health care, and that’s part of the issue, officials say.
If you’re unsure where to begin, people can always start with their primary care doctor, said Sheri Dawson, the director of the Division of Behavioral Health at the state Department of Health and Human Services. They can then refer you to a specialist, much like they would for a physical malady. She added it’s also important to check with your insurance carrier, which often has its own network of providers.
On Saturday, Andy Page was set to walk across the stage at the Lied Center for Performing Arts to earn his diploma. Now that he has law school behind him, he’s looking forward to working for a medical software company in Lincoln.
He knows that his stress level will probably go down with school over, but he said it was frustrating to not be able to access the mental health services when he needed them. He knows others are in the same boat.
“It’s definitely alarming,” he said. “We’re still in the COVID pandemic, but there’s kind of a mental health pandemic … everybody’s overwhelmed. Everybody’s getting hit hard.
“I really don’t know a person that I’ve talked to recently that has everything together.”
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Elaine Van Volkenburg
Contact the writer at firstname.lastname@example.org or 402-473-7225. On Twitter @HammackLJS