As Covid-19 continues to rage and almost a year since the murder of George Floyd, it's once again Mental Health Awareness month. With everything going on, the number of Americans experiencing anxiety and depression is up — 42% of U.S. adults reported symptoms, up from 11% in previous years, according to a December survey from the U.S. Census Bureau.

As challenges like Covid-19 and the reckoning on racism continue to take a toll on Americans' mental health, it brings new urgency to some of the long-standing issues like the cost of accessibility of care. Here's what you need to know.

The cost of mental health

Nearly 1 in 5 Americans has some type of mental health condition.

Spending on mental health treatment and services reached $225 billion in 2019, according to an Open Minds Market Intelligence Report. That number, which is up 52% since 2009, includes spending on things like therapy and prescription medications as well as stays in psychiatric or substance abuse rehabilitation facilities.

It doesn't take into account indirect costs, such as lower workforce participation rates and decreased productivity. In fact, depression alone is estimated to account for $44 billion in losses to workplace productivity, according to a recent report from Tufts Medical Center and One Mind at Work.

And access to care can prohibitively expensive — even more so than physical health costs. An hour-long traditional therapy session can range from $65 to $250 for those without insurance, according to therapist directory GoodTherapy.org. 

A more severe diagnosis, of course, carries heavier lifetime cost burdens. A patient with major depression can spend an average of $10,836 a year on health costs. Meanwhile, a person with diabetes taking insulin can spend $4,8000 to manage their condition.

Access to care is limited

Beyond the cost of mental health care, access to care is improving but still a big issue.

Access and coverage for mental health and substance abuse treatments have improved in recent years thanks to the 2008 Mental Health Parity and Addiction Equity Act, which barred health insurers from making coverage for mental health more restrictive than for physical ailments. That law and other legal and regulatory updates helped stop blatant discrimination against behavioral health care.

But there are still a lot of medical and insurance loopholes that exist that make it difficult for patients to get affordable care, says Angela Kimball, National Director of Advocacy and Public Policy at the National Alliance on Mental Illness.

And there are many other factors too, she says.

Mental health and substance use treatment centers and clinics, for instance, tend to be concentrated in urban areas. Rural parts of the country tend to lack access to more specialized treatment options — similar to the barriers that exist in traditional physical medicine. 

In fact, more than 112 million Americans live in areas where mental health providers are scarce. States like Missouri, Arizona, South Dakota, Montana and Washington are among those with low rates when it comes to meeting the mental health needs of residents. On a national level, research shows that the U.S. is likely to continue to experience a shortage of mental health professionals through 2025. 

Many providers also still operate outside the health insurance system, so for patients, they are out of network, which is expensive, says Carol Alter, the system medical director for behavioral health at Dallas-based Baylor Scott and White Health. 

"Even with the number of psychiatrists and psychologists out there...there's nobody for people to go to," Alter says. 

Indeed, just 56% of psychiatrists accept commercial insurance compared to 90% of other, non-mental health physicians. (Insurers pay licensed mental health professionals like psychiatrists lower negotiated rates for their services compared to physicians with similar backgrounds and experience levels, and they are subject to more paperwork.) As a result, those seeking mental health care are over five times more likely to seek care from an out-of-network mental health professional than for medical or surgical services.

These factors have real-life consequences, Alter says.

"Oftentimes mental health disorders are under-diagnosed, and certainly undertreated. What generally happens is that most people don't get treatment for it, or they might get some treatment, but not effective treatment," she says.

In fact, less than half of Americans who have a mental disorder get proper treatment, according to National Institute on Minority Health and Health Disparities (NIMHD). Alter says only less than 10% of patients who have a mental health disorder actually get effective treatment.

And the numbers only get worse when you look at Black Americans — the percentage who are able to access treatment is only about half of that of white Americans, according to NIMHD.

The changing landscape

So what are some of the solutions?

One way forward is to increase the training and collaboration between primary care doctors and mental health professionals, Alter says.

"The fact is that most mental health problems are presenting in primary care — they're not presenting to a mental health professional," she says. "There are things that can be done to help the primary care doctors diagnose and do that better. It's not only doable, it's actually where primary care is going."

Another changing dynamic is the use and expansion of telehealth and teletherapy amid the pandemic, which studies have shown can be effective in treating many mental health conditions. Online counseling services like Talkspace and BetterHelp can cost less than traditional in-person therapy with pricing ranging from $60 to $90 per week. And Talkspace is covered by many major insurers, including Cigna, Humana and Premera Blue Cross Blue Shield.

But some of the recent teletherapy expansion is based on emergency legislation and guidelines that waived many existing restrictions, including the ability for mental health professionals to practice across state lines. There's an open question as to whether the waivers will remain in place when the pandemic ends and whether Medicare, Medicaid and commercial insurers will continue to cover these services at the same levels.

Another area that's ripe for change is Medicare, Kimball says. Right now, Medicare offers one of the worst coverage options for those with mental health and substance use issues. 

Medicare, for example, has a 190-day lifetime limit on psychiatric inpatient care. And while that may sound like a lot, it's woefully inadequate for those who are diagnosed with severe or chronic mental health conditions at a young age. 

Additionally, studies show Medicare does not offer a robust network of mental health professional, covering only about 23% of psychiatrists in the U.S.

Making changes to Medicare could not only improve coverage for participants, it could also spur changes throughout the insurance industry. "As a federal program it often serves as sort of the baseline that can really prompt commercial insurers in terms of what they're going to do," Kimball says. 

And while Kimball says she's hopeful that legislative and regulatory changes are on the horizon, she's concerned about getting care and treatment to those who need it today. For those looking for affordable mental health services, there are a number of organizations that can help. 

Kimball's organization, NAMI, has a helpline that offers free assistance and advice Monday through Friday, 10 a.m. to 8 p.m. ET. You can reach the helpline at 1-800-950-6264. The organization also offers a free, 24/7 crisis text that can be accessed by texting NAMI to 741-741.

The Substance Abuse and Mental Health Services Administration, which is a government agency, provides a treatment locator to help patients find low-cost treatment facilities across the country. 

The National Association of Free & Charitable Clinics and non-profit the Open Path Psychotherapy Collective also provide locator tools to help find mental health services at discounted rates.  

If you're currently employed, it's also worth exploring whether your company offers mental health benefits through an employee assistance program that may provide discounted or free services. 

"People today recognize the need for mental health and substance use care," Kimball says, but adds that the U.S. really needs to think about health care delivery in this country. "We need private insurers on board and we need to level the playing field so it's not just public programs that are holding all the water." 

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