Barriers to care

Treatment for depression by clinicians and other healers in the United States can be costly, and it is not always easy to find an available provider who is also affordable. Many young people we interviewed ran into barriers when they tried to get therapy, counseling, medication, or other forms of care. Often those who made it past these barriers were then unable to maintain this care over time. Devin said, speaking about other young adults as well as himself, “I think probably a lot of people can’t deal with their depression because they do not have the means for probably insurance or something like that… especially when it comes to money.”

Sierra Rose describes why it is 'so insanely difficult' to get help for depression.
Interview Transcript

Why is it so difficult to get help? If you want help if you’re trying to get help, why is it so insanely difficult to actually get it? There’s the financial aspect of it which on its own is overwhelming. Then there’s the trying to find a provider, the insurance, the, all of the technical stuff. Why can’t I just call up a therapist or you know, walk into the hospital and be like, “I need help. Help me.”

DEP Sierra Rose
Profile Info
Age at interview: 18
Sex: F
Age at diagnosis: 11

Background: Sierra Rose lives in an apartment with her boyfriend, another roommate, and three beloved cats. She spent a week in the hospital shortly before her interview, and was continuing with out-patient care but struggling to pay for some of it. She is Italian and Jewish.

Click here to view Sierra Rose's profile page

Insurance problems

A number of people we interviewed described having no insurance coverage to help pay for depression-related treatment, and many others said they had some useful coverage but it was inconsistent or insufficient. Echoing a story many people told, Leanna said she has been in and out of therapy for years: “Whenever I can afford it, whenever I actually have health insurance to be able to do it, I do it and it’s always pretty intense.” Sam said he “stopped taking medications, not on the advice of my therapist, but out of financial necessity;” Sierra Rose described the same thing. When Marty’s insurance stopped paying for methadone, he turned back to heroin.

Even when people had insurance coverage, the portion of the bill they were responsible to pay themselves (their “co-pay”) was sometimes so high it made care unaffordable. Leanna says she has to pay ninety dollars out of pocket for therapy visits, which “doesn’t sound like a lot but it’s hard for me to come up with it.”

Sally notes that in her insurance network, psychiatrists are considered specialists and the co-pay is a lot higher than for doctors who are not specialists.
Interview Transcript

I don’t know if it’s the best way, but then at the same time psychiatrists are considered specialists for insurance, so it’s more expensive with co pays and stuff like that so you know, it’s really, it’s really difficult to, you know, find a place where you could be. You know, get therapy and get the help you need and get the medication you need and not you know like fall in that crack.

DEP Sally
Profile Info
Age at interview: 25
Sex: F
Age at diagnosis: 19

Background: Sally lives with her boyfriend, dog and cat in an apartment in a suburb. She is in graduate school part time and works as a researcher. She is Middle Eastern/Egyptian.

Click here to view Sally's profile page

Another common issue people described is that only a limited network of care providers is covered by their insurance. Several people said it was hard to get access to a medical professional capable of prescribing medication (most often a psychiatrist) within their network. Others talked about difficulty in finding a good therapist. Pete, for example, said “it took a lot of searching” to find a therapist. He searched through 400 people “…to find someone that was available and that was taking the insurance. Because most people that are taking insurance have a lot of people coming and their times are really short and if they are not, it’s because they charge more.” Colin noted that there are “limited options” within his network, and he wishes he could “get around it” and go to other providers.

Frankie didn't have insurance for the longest time, and as a result didn't get treatment for depression or other issues. Now that she has insurance, she has a list of services that she wants to get.
Interview Transcript

… my parents didn’t have insurance and so any time we had to go to the doctor it was a really huge deal. The bill would be massive, so I felt way too bad to even suggest, “Hey, I want to go to a counselor. Hey, I want to do this.” Because I knew that would cost them hundreds of dollars, if not more, so that’s kind of crappy but.

You said now you have insurance. So what do you think are other things that you might pursue now that you, you might have better coverage for more services?

Oh boy. What’s, what’s funny is, as soon as it kicked in, I felt like a kid in a candy shop. Like, oh my god, I can go to a dentist. I’m going to go. I went to a nutritionist a few times. It wasn’t super helpful on the eating disorder side. That that’s what I was hoping, I was hoping it would be helpful but, you know it was just, ok. Yeah, I, we joined a gym because we could get a reimbursement for a lot of it. What else, what else. I don’t know. I feel like I’ve done so many things [Laughter].

You feel like a kid in a candy store?

Yeah.

That’s an interesting analogy [Laughter].

Yeah that’s what it felt like, like oh my god let’s look though this whole packet and see like all the stuff that we can do now [Laughter].

DEP Frankie
Profile Info
Age at interview: 24
Sex: F
Age at diagnosis: 13

Background: Frankie works fulltime in customer service and lives with her husband. She takes antidepressants is not in therapy. Ethnic background is Caucasian.

Click here to view Frankie's profile page

Paying for care directly

Several people talked about paying for services directly. Julia looked for places with sliding-scale fees that she might be able to afford. Brendan’s family found therapists-in-training at a local college who provided care at a price his family could manage.

Cost has been a barrier in getting couples counseling for Jacob, but he has the capacity to pay for it if he cuts out other expenses.
Interview Transcript

Is there any kind of health and support that you don’t have right now that you wished you’d had?

I could probably benefit from seeing a therapist again specifically in the relationship department. I’ve thought about starting some couples counseling not because we have problems, because I want to prevent problems. We’re, we’re doing just fine. I have no worries about that and I want to keep it that way. And I want to make sure that my depression doesn’t, you know, compromise that. So I would like some advice on specifics, you know, how do you deal specific situations? I think that would be very helpful.

Is there anything preventing you right now from getting that?

Not really. Maybe, maybe finances, but I’ve learned that that’s a terrible reason, because it doesn’t matter, doesn’t matter what your financial outlook is like. That’s getting help for depression is more important. So there are things that I am sure I can cut out to make room for that. And I actually have been doing some research on specific therapists for that reason. So I am actively moving in that direction.

DEP Jacob
Profile Info
Age at interview: 25
Sex: M
Age at diagnosis: 18

Background: Jacob is a software engineer at a large company. He lives with his girlfriend and a cat. He is White.

Click here to view Jacob's profile page

Insurance reform

The Patient Protection and Affordable Care Act of 2010 (sometimes referred to as the “Affordable Care Act” or “Obamacare”) changed the availability of insurance in significant ways. For example, it made it possible for young adults to stay on their parents’ insurance until age 26, and made it illegal for insurance to refuse to cover “pre-existing conditions.” Health reform also created state-based “marketplaces” through which low-income people enroll for insurance coverage that is subsidized according to income levels. A “health care parity” law passed in 2008 mandates that treatment for physical and mental health disorders be equal*,*1 in plans covered by this Federal Act.

A few people we interviewed spoke directly about how Health Reform affected them personally. Shayne, for example, said coverage she got under the Affordable Care Act started right when she turned 27 and needed it. “Thankfully,” she said, “I was able to not drop 1500 dollars on a month’s worth of medication.”

Whitney was able to find a psychiatrist who could provide her with some good care once the Affordable Care Act made it possible for her to get 'insurance through the state.'
Interview Transcript

You had to copay for medication. And I’m like I can’t even pay that. And so, sometimes I wasn’t able to afford my medications or able to get out there to get them. So I would lapse in a few days which would kind of make things start over again. And it was frustrating for me so sometimes I feel like it’s not even worth going out there anymore. Like I felt like the doctor would see me for ten minutes to ask me what was going on and he’s like “How you doing? Okay, so, what should we set up for next week?” That’s as much as he said to me. He didn’t ask me about my life, what was going on. Nothing. Now I, once the Affordable Healthcare Act was in place and, I was able to get insurance through the state and I found a psychiatrist who actually, first appointment sat with me for three hours asking me about my life. Getting to know me as a person and was able to identify my problem areas and what I needed help in. And he was able to find out my triggers, why I was acting the way I did, kind of learned my life story and it’s like I felt like a lot of the county workers were just pushing me in through the doors and pushing me back out. I wasn’t getting the help I needed. And it was really frustrating for a while there.

DEP Whitney
Profile Info
Age at interview: 29
Sex: F
Age at diagnosis: 9

Background: Whitney is unemployed and is staying with her father who has custody of her 9-year old daughter. She is White.

Click here to view Whitney's profile page

(See ‘Depression and school’, ‘Getting professional help for depression’, ‘Therapy and counseling’, ‘Depression, medication, and treatment choices’, and ‘Holistic and integrative approaches to depression’).

References

*“Implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA)”. Substance Abuse and Mental Health Services Administration, 15 June 2015, Web. 7 February 2016.

*1 “What is Mental Health Parity?” National Alliance on Mental Illness, n.d., Web. 7 February 2016.

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