Ken Libertoff had his jacket on and was almost out the door late one Friday afternoon when the phone rang in his office at the Vermont Association of Mental Health in Montpelier. 
The caller was a nurse at Northeast Kingdom Human Services  in Newport, and she was frantically searching for a psychiatrist to see one of the center’s clients. Libertoff is head of the leading advocacy group for the mentally ill in Vermont, but he’s not in the business of making referrals.
More importantly, he was quite certain that he wouldn’t be able to find a psychiatrist — even in Montpelier.
“It was profound,” Libertoff recalled, “in the sense that if a person was having a heart attack it would be a front-page story if they couldn’t get treatment closer than an hour and a half away.”
Vermont’s mental-health-care system is widely considered a model for other states. A network of 10 publicly funded community centers provides outpatient treatment for people who, in other states, would likely be hospitalized. And a parity law enacted 10 years ago requires insurance companies and employers to cover mental illness.
But, despite efforts to improve access to mental-health treatment, a shortage of specialists is making it increasingly difficult for Vermonters to find psychiatric care. Consequently, according to Libertoff, most mental-health treatment now takes place in a primary-care setting, where practitioners lack the time or expertise to deal with serious psychiatric disorders.
Alice Silverman, who has a private practice in St. Johnsbury and is the only psychiatrist in Caledonia County, said general practitioners do the best they can. But they lack the diagnostic skill to perform specialized evaluations of the biological, psychological and social factors that contribute to mental illness.
“Primary-care physicians are the least able to spend time to figure out the bio-psycho-social assessment, which is what a psychiatrist does,” Silverman said. “If you’re seeing 40 people a day, that’s not going to happen.”
In January 2007, Primary Care Vermont, a support network for general practitioners, surveyed primary-care doctors about their working conditions. The organization’s founder, Deb Richter, who practices in Cambridge, said one of the doctors’ major complaints was the number of mental-illness cases showing up in their offices.
“These are complicated cases that should be handled by psychiatrists, but there aren’t enough of them practicing,” Richter said. “We’re not comfortable with it, but when someone comes in and says they’re thinking about suicide, what can you do?”
Libertoff and other advocates agree the shortage is most acute at the state’s community mental-health centers, which treat about 6500 adult outpatients a year with just 15 psychiatrists among them.
Vermont budgets a little more than $7 million annually for that care, but it’s not nearly enough. More than two-thirds of the center’s clients have annual incomes under $20,000, and government-funded health-care programs don’t cover the full cost of treatment. Between 2002 and 2006, the centers ran a combined deficit of $2.7 million, according to a study by Pacific Health Policy Group, a consulting firm that specializes in health-care reform.
The study, commissioned by the Vermont Agency of Human Services , found that at some centers clients had to wait four to six weeks to see a psychiatrist, even for minimal services such as prescription refills. Other centers have capped or reduced their caseloads to serve only those who might otherwise end up in the emergency room or Vermont State Hospital .
“We do the best we can to spread the services out as broadly as we can by using each psychiatrist as efficiently as possible,” said Julie Tessler, director of the Vermont Council of Developmental and Mental Health Services, Inc . “But there have been times when our community centers have found themselves really on the edge in terms of having adequate psychiatric coverage.”
Tessler said the shortage of specialists is most dire in rural areas of the state, such as the Northeast Kingdom. But even at Burlington’s Howard Center for Human Services , which can rely on psychiatric residents from Fletcher Allen Health Care, getting an appointment for non-emergency treatment would take at least three weeks.
“If what you really want is a psychiatric evaluation, or we felt you needed a psychiatric medical opinion, that’s where the wait comes in,” said Todd Centybear, director of the HowardCenter. “We simply do not have the capacity to provide psychiatry at a time or place that would be most optimum.”
Centybear considers himself lucky: He can offer crisis care and a walk-in clinic. But even he worries about losing a psychiatrist. Annual turnover within the state’s community mental-health network is about 40 percent, and it takes an average of four to six months to recruit a replacement.
That’s because fewer medical students are choosing psychiatry, and those who do are in great demand at hospitals and medical schools, where the pay is higher and the caseload more manageable.
Both Centybear and Tessler pointed out that it takes a certain breed of physician who’s willing to be on call 24 hours a day and weekends to deal with the most difficult cases. “They are in such demand, they don’t need to do that,” Tessler said. “And the community health center — what can they say? You have to? If they get up and leave, it might take six months to hire another psychiatrist.”
Vermont’s parity law, which was expanded in 2006, is supposed to make it easier for people with health insurance to afford psychiatric care. But more and more private-practice psychiatrists are choosing not to deal with insurance companies, instead only accepting patients who can pay out of pocket.
Silverman runs her practice out of her home to keep it affordable. She treats patients regardless of their ability to pay, which means she makes about half of what most private psychiatrists earn. Medicaid and Medicare reimbursements are low, she said, and managed care “carve-outs” by insurance companies often refuse to reimburse psychiatrists for diagnostic evaluations.
Consequently, many psychiatrists are becoming what Silverman calls “psycho-pharmacologists.” “They make a lot more money by seeing people every 20 minutes and doing medication than they do by spending an hour and a half on a good assessment,” she said.
Before opening her own practice about four years ago, Silverman was the only psychiatrist at Northern Counties Health Care , in St. Johnsbury. She had about 500 outpatients and received about 10 referrals a week. She worked seven days a week.
When the center received a grant to integrate mental-health and primary-care services, Silverman asked for help. But rather than assume the additional cost, the center closed, leaving her patients without access to a psychiatrist.
“How could I find care for all these people?” she said. “I referred them to primary care.”