Editor’s Note: This story is part two of a three-part series on mental health in the Roaring Fork Valley. Read part one here.
Last year, Mental Health America — a non-profit dedicated to the promotion of mental health, well-being, and illness prevention — ranked Colorado as having the worst ratio of prevalence of mental illness to access to care in the country.
The relatively narrow portion of people accessing mental-health care — 53.6% of individuals with a mental illness received treatment in Colorado, according to 2022 MHA data — is partly due to workforce shortages in mental healthcare, cost of care, and ghost networks, according to Vincent Atchity, CEO and president of Mental Health Colorado.
The occurrence of ghost networks, according to him, happens when health-insurance providers ostensibly have a network of care providers for customers, but many of the care providers do not exist or are not accepting patients. Consequently, customers are left without access to quality care.
According to him, the Colorado Division of Insurance is tasked with identifying and addressing ghost networks but is struggling with enforcement due to the prevalence of the issue.
“It’s such a sprawling mess that it takes time to correct for, and the pipeline of folks going into providing care for mental health is not exactly a wild rushing geyser of people,” he said. “It’s tough work that is comparatively poorly compensated.”
In the Roaring Fork Valley, there are only three psychiatrists serving the region, according to Psychology Today’s database. And psychiatrists are not always accepting new patients.
A source who was under the age of 25 when searching for one in the Roaring Fork Valley said they faced difficulties associated with their age since the only psychiatrist available did not accept patients younger than 25.
“The big thing is going to be thinking about how we recruit providers to our area,” Aspen Outpatient Program Director at Mind Springs Health Kayla Bailey said. “The challenge that we consistently find here in our valley is that when we’re recruiting outside of this valley, the expectation is that the individual is going to have to find housing, which is very, very difficult.”
The 2022 Regional Health Assessment for Pitkin, Eagle, and Garfield counties also identified the lack of access to mental-health services in the area as a key issue. According to the report, there are 27.7 psychologists and 43 licensed clinical social workers per 100,000 people in the region. Statewide, there are 43.9 psychologists and 75.3 licensed clinical social workers per 100,000 people, although the state’s demand for mental-health services still exceeds the capacity of available resources.
After surmounting the challenge of finding a psychiatrist who is accepting patients, the cost of seeing a psychiatrist can be prohibitive — the initial appointment costs between $300 and $500 without insurance and subsequent appointments cost between $80 and $200 on average, according to K Health, a consumer health company.
HeadQuarters, a Basalt-based, mental-health organization focused on mental fitness, has a Mental Health Fund aimed at providing financial assistance for mental-health services. The fund allows local therapists to access subsidized therapy sessions for uninsured or underinsured clients, awarding up to 10 fully-funded therapy sessions.
The local requirement can present a challenge due to the limited availability of mental-health providers in the area. HeadQuarters Executive Director Angilina Taylor acknowledged that the mental-health landscape has evolved towards telehealth and said she hopes for the Mental Health Fund to eventually cover providers outside of the local region. However, she said that is not yet possible given the current funding available for the fund.
Atchity described a “non-system of a system” where Medicaid is set up to provide affordable care for eligible enrollees, but there are often long waitlists even if a client is eligible. Many providers also do not accept insurance at all, meaning that the cost of a session must come out of the patient’s pocket, according to him.
Bailey said that while most people who request services can be seen for mental-health counseling within a couple of weeks, the waiting period for psychiatric care can be much longer.
Navigating available mental health resources
Another major reason people are often discouraged from seeking help is due to the complexity of identifying and locating the proper care, according to Atchity. Scarce cultural competency, misdiagnosis, long waitlists, and a lack of inpatient psychiatric care contribute to the difficulty of accessing the appropriate resources.
The 2022 Pitkin Area Co-Responder Team annual report also found that multiple system involvement and a lack of communication among agencies and organizations can lead to confusion, creating a barrier to accessing mental-health services.
“When you’ve got a mental-health condition, regardless of acuity level, finding your pathway to care and supports and services is nowhere near as reliable and straightforward as finding your pathway to having an appendectomy or having a broken limb set or something like that,” Atchity said.
In April 2021, Gov. Jared Polis signed a bill into law establishing a statewide Behavioral Health Administration. The goal of the administration, according to Division Director of Policy and External Affairs Ryan Templeton, is to coordinate a cohesive and effective behavioral health system across Colorado.
Despite the duplicative efforts of behavioral health organizations, there are still many unaddressed gaps in the behavioral health system. He said the BHA is working on identifying and filling those gaps.
One of the issues he said the BHA has identified is a lack of access to services and a clear starting point for people seeking menta-health support. Termed a “front-door” or “no wrong door” approach, he said the BHA is exploring how to create a more straightforward pathway to accessing care. He said the BHA has anecdotally heard from Coloradoans that navigating the vast network of mental-health resources can act as a barrier to finding the right support services.
“If you go to a place to receive care, you should have access to the care that you need, whether it’s there directly or gets the coordination to or navigation where you need to go,” he said. Often, people report being discouraged after getting turned away from resources without any guidance on where to find the appropriate care they are seeking. “They just throw their hands up and say, ‘This isn’t a system for me.’ We can’t have that in Colorado. That’s how people die.”
Nowhere to go: Isolation in the Roaring Fork Valley
When Andrew Parrott was recently hospitalized at Aspen Valley Hospital for bipolar disorder, more than 40 hours passed before the hospital was able to locate a single available in-patient bed for him in the state of Colorado.
Once a bed was located, nearly a full two days later, he was transported five-and-a-half hours by a private security company to Colorado Springs. After receiving care in the hospital, he was discharged — still medicated — and left alone to face the task of getting home.
Parrott’s situation is not unique; in fact, the closest in-patient psychiatric care to Aspen is located in Grand Junction, still more than two hours away.
“We know that we’re lacking a lot of those beds in Colorado, a lot of those sites in Colorado, and access to those types of services,” Division Director of Policy and External Affairs at the Behavioral Health Administration Ryan Templeton said.
As of 2016, the Treatment Advocacy Center reported that there were 543 public psychiatric beds, or 10 beds per 100,000 people, in Colorado. That number is significantly less than the recommended minimum of 50 beds per 100,000 people to provide adequate treatment for individuals with severe mental illness.
According to Atchity, the in-patient bed shortage arose as the nation shifted away from asylums as people began to recognize they were not producing positive health outcomes, without implementing any alternative.
“As we closed those large warehousing environments, they were never replaced with anything to meet the needs of a critically ill population,” he said.
To address the shortage of in-patient beds, Templeton said the BHA is working on developing a reimbursement model that does not disincentivize higher acuity care. To do so, the funding streams must be associated with a certain level of care, complicating the funding plans.
Templeton said the BHA also plans to focus on ameliorating the insufficient availability of in-patient care by expanding “step-up” and “step-down” facilities, which refers to the continuum of care.
“We’re missing some of those spots to keep people out of those highest levels of care,” he said.
Bolstering community-based facilities — shorter-term care, such as crisis stabilization units and residential care — could help reduce the demand for psychiatric hospitalizations, according to Templeton.
In addition, he stressed the need for “step-down” or “step-out” support to facilitate smooth release from in-patient hospitalizations, improving the rate of bed turnover by ensuring that beds are continuously opening up as people are released.
While Parrott was eventually able to access the care he needed, the isolated nature of the Roaring Fork Valley can exacerbate mental health issues and impede access to supportive resources.
According to Aspen Hope Center Executive Director Michelle Muething, many clients experience feelings of depression and isolation because they are far from family members. Only a few cities have direct flights to and from Aspen, resulting in expensive airfare. The high cost of travel in Aspen can be a deterrent to people planning visits to family members in Aspen, or to Aspen residents hoping to travel to visit family members.
In addition, the dispersed geography and extreme weather conditions of Colorado can make it more difficult to access care.
“When somebody needs care, there is no local option,” Atchity said. “When somebody needs urgent crisis care, and it’s a blizzard outside, then your logistical obstacles are tremendous.”
Identifying gaps in care
Recognizing the sprawling network of resources and lack of coordination among them, Pitkin County Human Services created the Mental Health Access Program. Human Services Director Lindsay Maisch said a group of people in the mental health field have been working over the past few years to identify and fill gaps in the area’s system of care in order to reduce barriers to people accessing care.
MHAP was born out of that effort with the goal of establishing the infrastructure to collect cohesive community data. They accomplish that by partnering with Mind Springs Health, Recovery Resources, Aspen Hope Center, Mountain Family Health Center, and Aspen Valley Hospital to better understand how current funding is impacting the community.
“That’s a pretty good subset of who is accessing mental health services and at the community level,” she said.
The kind of collaboration facilitated by MHAP can help coordinate care across organizations addressing mental health and reduce redundancies in the work being done.
When Parrott found himself in the Aspen Valley Hospital, he said he noticed a lapse in communication between the Pitkin Area Co-Responder Team, which he had worked with previously, and the clinician he spoke with in the hospital.
Although he had already talked at length with PACT about his struggles with mental health, he had to go through the explanatory process again with another clinician as part of the intake process.
He said the people he spoke with from both PACT and at AVH were helpful and understanding, but the process could have been streamlined by coordination among responding agencies.
“I know that all of these organizations have the best intent … We can have people doing triplicate, if not quintuple the work, all overlapping with each other,” he said.
Creating opportunities for collaboration and communication among organizations through projects such as MHAP is one way to foster better communication.
In addition to collecting data, MHAP conducts weekly case conferencing to examine how referrals are made and where gaps in the system lie.
Through this work, Maisch said they have identified a “doughnut hole” in the care of individuals who are using substances and who are also suicidal.
“There’s not a place in our community for them to go because they can’t go to jail; the only other custodial place for them to go is the hospital; but typically, when somebody’s pretty heavily under the influence, it’s very hard to assess for suicidality,” she said. “It’s kind of this weird little doughnut hole that’s living in our community where we don’t know where people go, and it puts them at even higher risk and more barriers for them to have to overcome to get the treatment or care that they need.”
Addressing the root causes of mental illness
Regardless of the availability of mental-health services, people will continue to struggle with mental illness until its root causes are addressed, according to Atchity. The social determinants of mental health include environmental and behavioral factors such as access to childcare, affordable housing, and sustainable wages, among other factors.
“We’re going to be a state in crisis unless there is more emphasis on the bigger picture of human health and well-being,” he said. “All of these different social determinants of health … are stressors on human experience, and that there’s very little adequate provision for (them) in our communities. Clinicians are not going to solve our mental health crisis.”
He suggested that focusing on addressing the youth mental-health crisis, which begins in the perinatal ecosystem, is a good starting point in order to raise a healthy population from the ground up. That includes introducing a system of support for children and families that ensures basic needs are met and increasing access to mental health in schools.
“That’s how you build a system of care, is by building a healthy population because then you don’t have a system of care that is trying to react to a population that’s in a state of health distress,” he said. “You can’t build a system of care for a population that’s in a state of health distress. That’s exactly what our situation is right now in the United States.”
According to him, the current state of elevated tension that pervades American society introduces additional stressors to youth.
The American Psychological Association found that the increasingly devastating effects of climate change are disproportionately impacting the mental health of youth — nearly half of survey respondents between the ages of 18 and 34 said the stress they feel about climate change affects their daily lives.
In addition, Atchity said the pronounced political divisiveness prevents a commitment to improving the mental health and well-being of American communities.
“We’ve got a perfect storm of conditions leading to mental-health distress that there is no single clinical solution for,” he said. “It is a complex set of things that has a lot more to do with human communities getting their acts together, and realizing that prioritizing human health and well-being should be number one on everybody’s list.”