Psychologist Shandra Brown Levey stands in the fluorescent glow of a doctor’s office hallway, just outside an exam room. She waits quietly but eagerly: The man on the other side of the door struggles with his mental health but has been hesitant to tell anyone other than his primary care doctor, whom he’s visiting today. For months, he’s refused to meet with Levey’s team of psychologists, embedded here at the UCHealth A.F. Williams Family Medicine – Stapleton clinic. Levey hopes today is the day he finally lets her in.
The patient is hardly an anomaly. Nearly 660,000 Coloradans—about one in seven residents—claimed they did not get the mental health services they needed in 2019, according to the nonprofit Colorado Health Institute’s most recent Colorado Health Access Survey. That’s a 77.6 percent increase from 2017. Although the surge might represent more people acknowledging that they need care, it also reflects a serious dearth of access in the Centennial State. According to the survey, cost was the most prevalent reason for not seeking treatment, followed by uncertainty about whether insurance would cover it and difficulty getting an appointment. Meanwhile, Colorado ranks 10th in the country for deaths by suicide, and teen suicide deaths increased by 58 percent between 2016 and 2019—the highest rise nationwide.
Fortunately, Colorado’s behavioral health woes aren’t going ignored. Organizations all over the state are rallying to bolster services so people can access them when and where they’re needed—before a crisis arises. One of the biggest investments will come from UCHealth, which runs Levey’s clinic. Announced in September, the Aurora-based nonprofit health system’s more than $100 million, five-year spend includes expanding Levey’s integrated model (i.e., psychologists physically on hand in family care offices to help patients) across its network. The goal is to encourage medical professionals and patients to care for mental wellness as assiduously as they do the rest of the body. “You don’t think about depression the same way you think about diabetes, so maybe you don’t seek treatment—or if you do, it’s hard to find,” Levey says. “We’re trying to fix that.”
You only have to read ancient Greek tragedies to know that humanity has struggled with mental health problems for millennia. But our current crisis—at least as it relates to access—stems in large part from a movement in the mid-20th century to shutter public long-term care facilities and psychiatric hospitals. In 1963, President John F. Kennedy signed the Community Mental Health Act, signaling a shift from warehousing patients in institutions to delivering what’s called community-based care: outpatient treatment supported by then newly developed psychotropic medicines. The missteps that followed—including underfunding for community health centers—meant many patients got lost in the transition between the two models and never got care at all.
Perhaps as a result, mental illness and disorders “are the number one health crisis in our country,” says Vincent Atchity, president and CEO of Mental Health Colorado, a grassroots advocacy and lobbying group. He points out that most of us don’t know how to care for our “behavioral health,” a term that covers mental health, psychiatric disorders, and substance abuse. The deficits are especially pronounced for vulnerable populations. Nineteen school districts in Colorado, for example, have fewer than one full-time school psychologist or social worker.
The grave state of behavioral health care for young people has long been evident to practitioners at Children’s Hospital Colorado, which has invested $150 million into initiatives to address the issue over the past decade. Since the formal branding of its Pediatric Mental Health Institute in 2014, Children’s has greatly expanded its spectrum of care—inpatient services; partial hospitalization for kids who can sleep at home but need significant daytime support; outpatient programs with talk, group, and family therapy—and embedded behavioral health professionals in every corner of the hospital. “If a kid is admitted to the ICU, we have a behavioral health team member who comes in even before the child is medically stable,” says Shannon Van Deman, who leads the institute. After all, an adolescent who’s injured in a car accident might also show signs of suicidal ideation. “We’re trying to do our part to identify kids in need,” Van Deman says, “irrespective of why they’re coming through our doors.”
Still, in 2017, Colorado ranked 48th in the country for prevalence of pediatric mental health issues and lower rates of access to care. So that same year, Van Deman and other administrators and clinicians launched Partners for Children’s Mental Health, a statewide public-private partnership that researches why kids here are struggling and what changes could help. It discovered that Colorado doesn’t have a standardized behavioral health screening for physicians to administer and that 60 percent of kids who died by suicide visited their primary care doctors during the last month of their lives. The group advocated hard for Colorado Senate Bill 19-195, which passed into law in May and demands a standard approach to screening and a standardized system to get children whose exams reveal they need treatment in to a specialist. (The state has until July 2020 to figure out how to implement the mandates.) “If we don’t effectively address this in childhood,” Van Deman says, “it absolutely manifests in adulthood, and often in an acute way.”
Roland Delaney is soft-spoken and has a gentle, weary countenance that belies his warm smile. The 64-year-old served in the U.S. Navy from 1975 to 1992; upon his discharge, he started experiencing symptoms of post-traumatic stress disorder. He eventually tried to get treatment through the military and several different health care providers. Says Delaney: “They asked what my problem is, and I said, ‘I have this S on my chest that means I have to save everybody, and if I don’t save them, I feel real bad.’” But nobody seemed able to help him erase that letter—or give him relief from the dark places his mind and soul wandered. Which is why Delaney kept Levey waiting for months outside that exam room door.
Eventually, when the sadness and anger became all-consuming, Delaney relented. “Our first official meeting together was me crying and her listening,” he says. But Delaney came back regularly. Levey and the primary care doctor collaborated to adjust his medication, and Levey tried various evidence-based approaches to help the vet understand and deal with his emotions. Then, a breakthrough: Using a virtual reality headset and immersive software that leads him through mindfulness and mood exercises, Delaney says he found a way to “slow down and breathe and not feel alone” and avoid emotional dips between visits with Levey. Delaney bought a headset to use at home and recently revealed to her that he’s using it to learn Spanish. The only problems? “I’m having trouble talking to the [virtual] cab driver,” he laughs. “And sometimes my girlfriend thinks I’m talking to another woman.”
Levey says Delaney’s story is just one example of how bringing behavioral health providers to patients—rather than making them try to navigate the system—changes outcomes. Her office began providing integrated services decades ago, but UCHealth’s big investment will replicate the model by embedding counselors in dozens of primary care clinics in Colorado (and potentially southern Wyoming).
UCHealth isn’t the only local provider working to beef up front-line services. Two years ago, SCL Health launched Mental Health First Aid, an eight-hour training program managed by the National Council for Behavioral Health and Missouri Department of Mental Health that equips community members—such as teachers, first responders, and business owners—to recognize risk factors and warning signs for behavioral health issues and teaches them what to do until professional help arrives. At Kaiser Permanente Colorado, for several years physicians have been able to call the Mind Line and reach a psychiatrist for quick advice on a patient’s medication or to get an urgent referral to a specialist.
The hope of all these approaches? That by meeting patients where they are, health care providers can finally begin to chip away at the enormous behavioral health needs in Colorado. “I deal with more complex mental health needs than you might expect in primary care,” Levey says. “It makes sense, because we’re the first line of defense, the first people to step through the door and say, ‘I’m here. I’m your person. Let’s help you get well.’ All it takes is the patient opening one door.”