WSJ reporter Gary Fields discusses his series about the shortage of treatment for the mentally ill and its impact on families, communities and the criminal justice system.
LEONARDTOWN, Md.—To the outside world, it came across as mood swings and anger. But Regina Cullison would later be told by psychiatrists she struggled with depression and anxiety—and that she needed help. And that is where her trouble began and ended.
According to her mother, there were few psychiatrists in the county who took private insurance. When Ms. Cullison lost her job as a dentist's assistant, and with it her insurance, she switched to a nonprofit facility. Doctors came and went, and none stayed long enough to establish a regular pattern of treatment.
After two years, Ms. Cullison abandoned her search for professional help and tried marijuana. Her mother, Carolyn Cullison, who is the director of a mental-health peer support group, said that helped push away the demons. But in May, while living together, the pair argued. Ms. Cullison apologized, retreated to a bedroom and shot herself. She was 26.
As hard as it might be to acknowledge having a mental-health illness, finding professional help can be even harder.
Last year, according to the U.S. Department of Health and Human Services, almost 91 million adults lived in areas like here where shortages of mental-health professionals made obtaining treatment difficult. A departmental report to Congress earlier this year said 55% of the nation's 3,100 counties have no practicing psychiatrists, psychologists or social workers, a combination of budget cuts and doctors leaving the profession.
Even in well-served areas, such as Washington, D.C., and Massachusetts, demand is so high practitioners frequently decline to take new patients or private insurance, according to a Kaiser Family Foundation survey.
Such shortages are expected to only grow now, as the federal health-care law goes into effect and allows more people to seek help. Indeed, according to the National Association of State Mental Health Program Directors, some 6.8 million uninsured people with a mental illness will gain coverage after federal and state health insurance exchanges implement the new law. More people will be chasing after scarce resources, an influx that will "overwhelm if not inundate" the field, said Dr. Jeffrey Lieberman, president of the American Psychiatric Association.
For years, much of the country's struggles with mental-health treatment remained out of the spotlight. But a series of high-profile shootings over the past two years, such as in Aurora, Colo., and Newtown, Conn., and Tucson, Ariz. has drawn attention to a host of deficiencies. Those include privacy laws that end up limiting families' ability to guide their children's care and a tightening of commitment standards that exclude all but the most obviously violent patients. The result is increasing and sometimes fatal encounters with police and prisons overflowing with the mentally ill.
In one recent tragedy, Virginia state lawmaker Creigh Deeds, a former Democratic candidate for governor, was stabbed last month repeatedly by his son Gus, who then died of what the police call a self-inflicted gunshot wound. The incident happened one day after the younger Deeds was released from a mental-health facility where he was taken for an assessment.
Mr. Deeds, who tweeted after being released from a hospital that he must live on but that "some wounds won't heal," didn't respond to a request for an interview. A spokesman for the facility declined to comment, citing family privacy. The case, however, has led to a state investigation into the treatment the younger Deeds received, and prompted the governor to propose funding increases.
Carolyn Cullison, Regina's mother. Melissa Golden for The Wall Street Journal
Between 2005 and 2010, when the general population grew 4.7%, the number of psychiatrists in the U.S. barely changed, dropping slightly from 38,578 to 38,289, according to the Association of American Medical Colleges. In addition nearly 57% of the psychiatrists still practicing are at least 55 years old, meaning they're often both established and approaching retirement and more likely to only take patients who can afford to pay out of pocket.
"A lot of them say: 'You pay me and if you can collect from your insurance, good luck,' " said Donald Malone, head of the psychiatry department at the Cleveland Clinic in Cleveland.
Once considered lucrative, the profession has come under pressure as insurers have cut back on payments. The mean income for psychiatrists—$186,000 a year—ranked 19th out of 25 medical specialties, and rose only 1% in 2012, according to Medscape, a unit of WebMD Corp, a health website. Some experts worry that as more patients flow into the system, providers will choose to forego working with insurers.
For now, many people are simply trying to cope. Richard Furstein, 21 years old, a senior at Drexel University in Philadelphia, says he hasn't been able to find a psychiatrist who will take his insurance. Mr. Furstein said he started to realize he needed help last year after having "days I couldn't get out of bed. I was just frozen." He says he was overwhelmed with school work and applying for a fellowship. Doctors treated him for a mouth infection, he said, and eventually referred him to a psychiatrist after his struggles persisted.
Mr. Furstein said he called Drexel's health center and a school-affiliated hospital, and was told he could see a psychologist but would have a much longer wait for a psychiatrist. School officials, while declining to discuss his case, confirmed that it can take a few weeks to see a psychiatrist, unless the need is more urgent For his part, Mr. Furstein said he and his mom and stepdad looked for other help, but couldn't find a psychiatrist who would take their insurance. "I see it all the time with my kids and parents," said his mom, Margo Moses, a school nurse. "They don't get the services they need."
Mr. Furstein is now seeing a psychologist his parents found, who is in the process of determining whether Mr. Furstein has a mental illness and needs medication. That would prompt a renewed search for help since the psychologist can't write a prescription.
"I just feel alienated and ignored," Mr. Furstein said.
The Mental Health and Mental Retardation Authority of Harris County, Texas, covers Houston, the nation's fourth largest city. After years of budget cuts, it has a waiting list of 1,600 adults seeking treatment for the most serious mental illnesses of bipolar disorder, schizophrenia and major depression. The agency treats almost 50,000 people a year, making it the largest mental-health services provider in the state.
Steven Schnee, its executive director, said people with other often disabling anxiety or obsessive compulsive disorders typically aren't eligible at all.
He recently received fresh state and federal funds to cut the wait list, but that doesn't do much to ameliorate his biggest concern, which is recruitment of doctors. "We have a significant shortage of psychiatrists in the state at time when we are seeking to expand services," said Dr. Schnee, a psychologist.
Katherine Nordal, executive director for professional practice at the American Psychological Association, said treatment shortages tend to be concentrated geographically. She estimates the number of mental-health providers nationally is 500,000 to 600,000. Yet when she practiced in Vicksburg, Miss., the nearest psychologists were an hour east in the state capital of Jackson. "There wasn't a psychologist within 75 miles of me in any other direction," she said.
While living near Tampa, Fla., Jessica Baynard, 23, said she was diagnosed with bipolar disorder in 2009 and has been struggling to find proper treatment since. Through a county program, she says she went to a psychiatrist but visits were so brief he was "writing a prescription before I even sat down."
The doctor recommended therapy with a psychologist or counselor but her county-funded health insurance wouldn't cover it. At times she suffered from hallucinations and muscle cramps that appeared to be side effects from her medication. Eventually Ms. Baynard found a different doctor and was down to one medicine, Lamictal, which she says helped.
However, last November, Ms. Baynard lost her county-funded Florida insurance when she moved out of state and was rejected for Medicaid. Her medications then ran out earlier this year, she said, and she weaned herself off after failing to find affordable treatment. Her mother, Lori Baynard, said she is fearful. "You just hope and pray to God there's not going to be a massive episode."
St. Mary's County, home to the Cullisons, while considered rural, isn't remote. About 60 miles from Washington, D.C., its 108,000 residents make it one of the most populated counties in the country that struggles with treatment options, according to data from the University of North Carolina, which has studied the issue. The median household income of $82,529 is 56% above the national median and the value of homes is nearly twice that of the national average.
But St. Mary's has few, if any, full-time psychiatrist taking private insurance. According to the UNC data, 70% of its residents have inadequate access to mental-health care.
People with mental-health problems drive to Bethesda, Silver Spring, Annapolis and Baltimore, each up to two hours away, for treatment, said Amy Henderson, the immediate past president of the board of directors with the National Alliance on Mental Illness Southern Maryland, the local arm of the national advocacy group.
Bill McAloon, a 72-year-old veteran who says he suffers from serious depression and bipolar disorder, is one of the locals who makes the trip. "You think I like the drive to Bethesda?" he asked. "Two hours in a car in the midst of a manic episode is unpleasant," he said.
“Once considered lucrative, psychiatry has come under pressure as insurers cut back on payments.”
People who offer mental-health services in the county say they have tried to recruit psychiatrists, touting the area's proximity to Washington, D.C., its good school system and natural beauty.
"A big problem that we and other providers have had is attracting and retaining psychiatrists," said Gerard McGloin, executive director of Pathways, a private nonprofit that is one of the larger providers of mental-health services in the county. The departures are disruptive given how important trust can be in treatment, he said.
Nurse practitioners who specialize in mental health can write prescriptions, in some cases. Mr. McGloin said Maryland state law requires nurses have a formal agreement with a supervising doctor before they can prescribe medication for mental illness. With the shortage of psychiatrists, nurse practitioners must find doctors outside the area to work with them and some are "uncomfortable with that long-distance oversight relationship" and won't do it.
For Mrs. Cullison, the hardest step was getting her daughter to agree she needed help. She joined her daughter at the first appointment with Dr. Carol Paris. "There was no smile, no warm fuzzy feelings at all," Mrs. Cullison said. Knowing her daughter, she wasn't optimistic.
But Ms. Culllison saw something in the psychiatrist. So did her mother. "This was someone who would stay with you for an hour" and not rush through appointments, Mrs. Cullison said.
After Ms. Cullison lost her job and her insurance, the family couldn't afford to pay out of pocket. She switched to a community-treatment facility that handles people with low income and no insurance. There, a rotating cast of psychiatrists treated Ms. Cullison, her mom said, and often each new doctor would start her treatment regimen from scratch. That happened sometimes as frequently as every three months. She gave up after two years.
St. Mary's County mental-health officials didn't respond to repeated requests for comment. Dr. Gayle Jordan-Randolph, Maryland's Deputy Secretary for Behavioral Health, acknowledged the lack of treatment options in the area. "There are shortages in Southern Maryland, the Eastern Shore, Western Maryland and quite honestly we have gaps in urban areas," she said.
Dr. Paris, who had treated Ms. Cullison, said she was saddened by her death, but said she could not talk about her treatment, citing privacy laws.
The doctor, who is now participating in a one-year program that provides mental-health care in remote areas of New Zealand, said mental-health treatment was spotty in St. Mary's County. "It's that way partly because there simply aren't enough providers and when there are enough, unfortunately they don't stay."
Dr. Paris said she had about 1,000 patients and she agreed to take insurance "because I didn't go into psychiatry just to take care of rich people with loads of money who could pay me out of pocket." As her career progressed, she made less money each year primarily because of the falling reimbursements from insurers.
She said she stopped practicing because of frustration with insurers and the administrative requirements stemming from the new health-care law. She closed her practice in 2012 after trying unsuccessfully to sell it. "There was nobody to sell it to," she said.
—Louise Radnofsky and Rebecca Ballhaus contributed to this article.