Crisis state Crisis state Crisis state

Washington has a shortage of mental-health workers and high demand for treatment. The UW is at the center of efforts to turn the tide.

By Hannelore Sudermann | Illustration by Stuart Bradford | September 2021

When he is on night shift at Harborview Medical Center, James Lee is often the only resident psychiatrist on duty. The junior clinician walks the hallways, checking on as many as 100 patients. If they’re not sleeping, they may have immediate and serious needs. Most likely, they have come in through the hospital’s emergency department because they’re grappling with profound issues like severe depression, suicidal thoughts or behavior, or psychosis, he says.

Most of the patients will rest through the night in the safety of their beds, and they’ll wake to find a team of nurses, physicians, therapists, social workers, and chemical dependency counselors to help them through their psychiatric emergency. Others will require more immediate attention, and Lee will work to find the right balance of medication and other support for each of them. Some of the patients would not need to be in the hospital at all if they had better access to resources in their community. Their emergencies might have been avoided if the state’s mental-health system wasn’t failing, “if we had stable housing, or if we had a clinic that wasn’t booked six months out,” he says. On his rotations at Harborview and Seattle Children’s, Lee has had a view of some of the region’s most immediate mental-health challenges.

This is a crisis, says Jürgen Unützer, who, as head of the UW’s Department of Psychiatry and Behavioral Sciences, knows something about crises. “Washington has one of the highest rates of individuals struggling with mental health and addiction problems in the country, but we don’t have nearly enough mental-health professionals,” he says.

At some point in their lives, nearly a quarter of Washington residents will struggle with a mental health or addiction problem, but nearly half of the state’s 39 counties don’t have a single psychiatrist or psychologist to help. According to a recent state-funded study, Washington has just one mental-health provider for every 360 people. People who have less severe or less immediate concerns, may have to wait months to see a mental- health specialist. And when patients experience crises, their local doctors may not have the expertise to help them. If they need to be hospitalized, there often aren’t enough hospital beds in their communities.

There is no family that hasn’t been affected by a brain health, mental health or addiction problem at some point in their lives.

Jürgen Unützer, head of the UW’s Department of Psychiatry and Behavioral Sciences

Unützer seizes every opportunity to make these points. “More than a half-million Washingtonians with mental-health problems don’t have access to care,” he says. “And our communities are seeing the effects—in our streets, in our emergency rooms, in our jails and in our families.” This isn’t just an issue for other people. Mental health is everyone’s problem, he says. “There is no family that hasn’t been affected by a brain health, mental health or addiction problem at some point in their lives.”

As chair of psychiatry, Unützer leads a department of more than 1,000 faculty, staff, and trainees who work to provide clinical care and consultation and to train and inform a mental- health workforce for a five-state region in the Pacific Northwest (Washington, Wyoming, Montana, Idaho and Wyoming). UW’s Department of Psychiatry and Behavioral Sciences operates the largest psychiatry residency training program in the country and trains dozens of psychiatrists, medical students, clinical psychologists and other mental health professionals each year.  Department faculty also conduct critically needed research to find better treatments for serious mental-health and addiction problems, work that is supported by grants and contracts of around $50 million a year.

While Washington is known for many favorable ‘health indicators’ that are the envy of most other states, “with mental health, we are sadly ranked near the bottom of the pack,” says Unützer. “This is not something we are proud of. We need to make sure that the care we can offer a person struggling with a mental-health or addiction problem is just as excellent as the care we offer in other areas of health care such as cancer or heart disease.”

Part of the problem is a long history of neglect and little public support for mental-health care. That historic lack of support from the public is due, in part, to the stigma associated with mental illness and addiction problems. According to the American Psychiatric Association, more than half of people with mental illness don’t receive effective care or delay seeking treatment because of the associated prejudice and discrimination. Fortunately this is starting to change. “People are no longer OK with feeling burned out, with having their lives upended by mental illness, and they are starting to ask for help,” Unützer says.

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The state’s mental-health crisis came to national attention in 2018, when Washington’s largest mental hospital, Western State, lost both its federal certification and $53 million in annual funding. With 800 beds and a responsibility to handle the state’s forensic patients—those found not guilty of a crime for reasons of mental illness—the hospital had struggled with deteriorating facilities, staffing shortages, patient assaults and escapes of violent patients.

The hospital, a red-brick structure built in the late 1800s, is in Lakewood, just south of Tacoma. It looks something out of an old movie, says Unützer. “When we consider the amazing new facilities we have in our community to care for patients with other medical illnesses such as cancer and heart disease, it’s hard for us to look a family in the eye and say this facility, which is more than 150 years old, is the place where we provide care for our citizens who struggle with the most severe brain-health and mental-health problems.”

But Washington’s challenges date well before the shortage of mental-health specialists and the recent concerns at Western State Hospital. In the 1970s, Northern State Hospital, which cared for hundreds of individuals living with severe mental-health problems on a beautiful 1,086-acre campus with sweeping mountain views and a working farm, was closed as part of a nationwide trend of deinstitutionalization. That was followed by more closures of residential-care facilities through the 1980s, putting thousands of people with severe mental illnesses on the streets or in smaller, inadequate facilities. Today, those with persistent or severe mental illnesses often end up homeless or in nursing homes, medical hospitals, jails and prisons.

It’s important to recognize that mental health is not just somebody having schizophrenia, says Anna Ratzliff, ’09, a psychiatrist, professor and director of the UW Psychiatry Resident Training Program. At the other end of the spectrum are people grappling with issues like anxiety or depression. “Ten percent of the population will experience depression at some point of their life,” she says. If the UW experts can support their colleagues in primary care treat patients with these milder cases, that would free up the existing mental-health experts to work with patients struggling with more severe illnesses such as psychotic disorders or severe posttraumatic stress disorder.

Often, people will talk about their mental-health concerns with their family physicians rather than seek out a specialist. But most primary care doctors aren’t trained or experienced when it comes to dealing with complex mental-health or addiction problems.

Patients typically have to wait weeks or even months to see a psychiatrist even if they have access to one.

Ryan Kimmel, ’97, ’01, psychiatry chief of service for UW Medical Center

“Patients typically have to wait weeks or even months to see a psychiatrist even if they have access to one,” says Ryan Kimmel, ’97, ’01, psychiatry chief of service for UW Medical Center. “This is not unique to Washington. Across the country, patients are more likely to get help for their mental-health issues from their primary care doctor than from a mental health specialist.”  The challenge is finding ways to leverage the psychiatrists we do have in Washington to reach and help more patients across the state, he says.

Two years ago, the state launched an innovative consultation line where medical providers anywhere in the state can call a psychiatric expert at UW for advice. A doctor at a clinic in Friday Harbor, for example, can talk to an expert at UW about a complex case and get real-time advice about diagnoses and treatment options. The line is open 24 hours a day as urgent mental-health concerns often come up after normal working hours.

“With this resource, we can do a lot of good,” Kimmel says. “It allows primary care doctors to call us, ER doctors can call from rural emergency rooms. We also get calls from nurse practitioners and physician assistants and all kinds of health-care providers around the state.” Seattle Children’s has run a similar program connecting callers with a child psychiatrist for nearly a decade. UW Psychiatry also operates separate consultation line focused on perinatal psychiatry. “These programs help fill an enormous gap in our state,” Kimmel says.

The help line provides access to about 50 experts at UW. “Psychiatrists in our department specialize in virtually all areas of psychiatry ranging from geriatrics to addiction medicine and in challenging cases that come up at the intersection of psychology, neurology, and other brain-health problems,” says Kimmel. “I can often find one of our faculty experts who is well-versed in whatever the community prescriber is calling me about.”

This spring and summer, the hotline has received up to 100 calls month. Kimmel is grateful the line started up in 2019, before the outbreak of COVID-19. “A lot of people were suffering previously, and the pandemic just made things worse,” he says, citing increased isolation, stress and anxiety, job loss, friends and family members dying. Alcohol and substance use also went up during this time and brought a record number of deaths from drug overdoses in the past year.

Health-care providers who have used the consultation line are quick to share their gratitude. “In family practice, I work with general mental-health struggles—primarily with anxiety and depression … but when it comes to complex mental-health issues such as bipolar disorder, PTSD and ADD/ADHD, I need help,” wrote a Thurston County physician. “As we are all aware, access to psychiatric services in this state is quite limited depending on what county one resides in.”

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In the past few years, Unützer has logged countless hours championing better access to mental-health care with legislators, business and community leaders. He has testified before the Legislature, advocating for funding to train more mental-health workers and to build a new behavioral health teaching facility at the UW School of Medicine. He is hopeful about the state’s investment in this area. “Ten years ago, maybe only one or two legislators had a personal passion for improving mental-health care in the state,” he says. “Today this is on everyone’s radar screen.”

In 2019, Washington State Rep. Frank Chopp, ’75, sponsored a bill to improve access to behavioral-health care and support and expand the behavioral-health workforce in the state by establishing a new teaching hospital at the UW. At a hearing introducing the bill, he shared memories of visiting his sister years ago in the inpatient psychiatry unit at UW Medical Center. Unfortunately, it hasn’t much changed, he said. “We need to do better,” he added. “We are so woefully inadequate in many fields, especially in workforce.” The bill passed the House and the Senate with unanimous approval.

In April, the Legislature approved full funding of $234 million for a new Behavioral Health Teaching Facility at the UW Medical Center—Northwest campus in the Northgate neighborhood. The new facility will add badly needed capacity, bringing on-line 75 new beds for long-term civil commitment patients with some of the most severe mental-health and addiction problems as well as 25 beds for individuals who need medical or surgical care in addition to mental-health treatment.

The new resource will also create a state-of-the-art facility to train students in nursing, medicine, pharmacy, occupational and physical therapy and other health disciplines to work with patients with serious behavioral health problems. A state-of-the art neuromodulation center will be able to offer treatments for some of the most severe psychiatric illnesses and a 24/7 telepsychiatry consultation program will provide clinical consultation to providers in community-based hospitals, nursing homes and clinics throughout the state.

“This is a big step towards addressing the problems the state is facing,” Unützer says. “We will have a state-of-the-art facility where we can train people across medical disciplines to work together, where patients will feel welcome, and where families will have hope for their loved ones.”

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The work of changing public attitudes and stigma around mental-health care is also bolstered by high-profile gifts and grants, like the $38 million gift announced in May from the Ballmer Group, co-founded by philanthropist and civic activist Connie Ballmer and former Microsoft CEO Steve Ballmer, to help strengthen the state’s behavioral-health workforce. The grant will support training and apprenticeship opportunities for a wide range of individuals ranging from peers to undergraduate students and graduate students working in social work and other areas of mental health. It will also direct $8.5 million to the Behavioral Health Institute at Harborview Medical Center to expand training for early and mid-career professionals and to help redesign the state’s behavioral health crisis system.

More champions for mental health have recently stepped forward. In 2019, philanthropists Lynn, ’57, and Mike, ’61, ’64, Garvey gave $50 million to establish the Garvey Institute for Brain Health Solutions at UW Medicine. The institute fast-tracks treatments to reduce common mental-health and brain-health problems such as cognitive aging, trauma and addiction.

“Gifts like these send a strong message to our community and to our state and business leaders that mental health is just as important as physical health, and that we cannot have good health without good mental health,” says Unützer.

The pandemic has also shed new light on the need for mental-health support, bringing home to individuals and their employers that we can’t ignore our mental health. “A lot of things are hitting people’s health right now,” says Mollie Forrester, director of patient and family experience in the Psychiatry & Behavioral Sciences department. But a positive aspect of that is mental health is now more in our collective awareness. People are now more willing to ask for the help they want and need, she says.

All these things together—the growing public awareness and diminishing stigma, the investment of state funds to train more mental-health workers and to increase capacity for treatment, and the efforts of businesses and philanthropists to focus on behavioral health—paint a brighter future.

In medical school, psychiatry isn’t the most sought-after specialty, says James Lee. But he chose to focus his studies there because he could help underserved populations—including the LGBTQ+ community, people of color and children. The work is “tiring,” he says. “The patients I’m seeing now have higher levels of needs. A lot of my patients are well-known to the system, where the system has failed them or their illness is so severe, you can’t support them.”

When he finishes his residency, Lee is thinking about becoming a child psychiatrist. “Whatever I choose to do, at the end of the day I want to come home and feel I worked with the patients I cared about and gave them the best possible care.”