I need help, but I'm worried about it.

August 4, 2010 8:55 AM

I need to get help with my mental illness, but I don't know who to see or where to start.

Mid-twenties female anxiety sufferer here. The last two years on this earth have been incredibly stressful, which has turned my mild anxiety into a monster. I've experienced breakups, got engaged (and am planning a wedding), deaths in the family, illnesses, and I've been going to school full-time and working full-time. Currently I'm taking a year off from school, but I'm also dealing with recurrent infections and a new case of sciatica. The reason for the sciatica is unknown, as is the reason for my recurrent infections.

Needless to say, I've reached a breaking point in my life. I feel that my anxiety is making it harder for me to heal mentally and physically, and it's also putting a lot of strain on my wonderful fiance and our relationship. I am ready to get help with my anxiety and stop this cycle.

However, I don't know where to start.

I've talked briefly with my PCP about my concerns, but I haven't had a full discussion with her. My insurance (Keystone POS in Philadelphia, PA) requires that I get "referred". Does this mean I must go to a doctor that my PCP recommends, or do I choose my doctor (from the list of docs my insurance provides) and then call my PCP office and get them to put a referral in the system? I really don't like visiting my PCP more than I already do, so going to her for this seems like massive overkill. I'm also worried that she'll begin to doubt me or get annoyed when I come in for other issues.

Which kind of doctor should I see? Should I discuss this with my PCP first, or do I decide myself? I think I would benefit from both therapy of some sort and medication. I know that a psychiatrist would be the kind of doctor I need to see for prescription meds, but would s/he help with therapy, or would I need to see two different people? My insurance has two different sections with two different coverage and copay amounts. One is "Mental Health" and the other is "Serious Mental Illness". Which one (or both?) would I fall into? One requires a copay and is limited to 20days/calender year and the other is 100% covered and is limited to 35/calender year. Does a psychiatrist fall into one and a therapist fall into the other?

Thanks for your help. This is a sock puppet, so please feel free to ask questions and I'll respond. Bonus: if you've had a great experience with any kind of mental health professional in Philadelphia, PA, please feel free to recommend them in-thread or by me-mail.

posted by your mom's a sock puppet to health & fitness (11 answers total)

Studies indicate the most effective treatment is a combination of meds and therapy, so I'd pursue both at this point. Finding providers can be like dating; you'll met some you dig and some you wouldn't touch with a 10 foot pole. Don't be discouraged! It can be frustrating for everyone. It's good you're taking this step.
posted by ShadePlant at 9:26 AM on August 4, 2010 [2 favorites]

Firstly: you (and your insurance) are paying your doc's salary. And your complaints (infection, sciatica, anxiety) are all fully legit and may require multiple visits to fully square away. If she doubts you or makes you feel guilty, get thee to a new PCP pronto.

Secondly: I'd research in-network doctors on IBX's website, find a handful who seem like a good idea, then bring this list to your PCP. I believe you can have a say in the specialist to whom you're referred.

Thirdly: if you want to explore both meds and therapy, you are generally (but not always) talking about two separate professionals. The psychiatrists I have dealt with have been "prescribing docs" - you visit a wee office covered in Cymbalta posters once every three months and pick up a new scrip, and that is that. Conversely, your therapist may be a Ph.D, an MSW, an LSW, etc., and you'll see them more frequently.

Fourthly: re: "Mental Health" vs. "Serious Mental Health" - they're referring to outpatient vs. inpatient care. Unless you feel you are suicidal or a danger to yourself/others in some way, you'll be dealing with outpatient. 20 visits a year means you can go roughly every two weeks and pay a copay each time.

In summation:

- Do some research on IBX's site. Find therapists. Research therapists. Make list.
- Book appointment with PCP. Bring list. Discuss two referrals: a prescribing shrink and a therapist. DO NOT FEEL GUILTY OR INTIMIDATED IN ANY WAY by your doc - you are full deserving of help!
posted by julthumbscrew at 9:28 AM on August 4, 2010

Usually if you need to be referred, it will be up to your PCP whether she wants you to come in for a visit before she will refer you. Also, most PCPs aren't going to make you go to a single doctor they recommend, most are willing to let you choose and then refer you. It's more like the PCP just needs to refer you to a mental health professional in general to show your insurance that you "need" to go to one. It's just like if you needed to go to a specialist, like an allergist or GI doctor. Your insurance doesn't want you to just go to random specialists without your PCP saying it's needed, because they don't want to pay for that.

It's generally up to you what kind of doctor you see, and your PCP might have recommendations. Often people see a separate psychiatrist from their therapist, sometimes you go to one person for therapy and meds. If you don't want meds, you can just go to a therapist. You can go to a PhD psychologist, or a therapist who just has a masters, usually in social work or psychology, though some have M.Ed or other degrees.

As for your insurance, you will need to call and find out what coverage you should use. On some plans you also have to get pre-approval for mental health visits before you can see one. Most likely, however, the "serious mental illness" part is for conditions that require inpatient treatment.
posted by elpea at 9:30 AM on August 4, 2010

Call your PCP's practice and say that you think that you need to pursue treatment for anxiety and do they have someone to which they can refer you. I don't know that it will be necessary for you to have an office visit with your PCP for this, but I doubt it (though you should not think that she'll doubt you or get annoyed when you come in for other issues.) It probably depends on how your insurance is set up and the preference of the PCP?

The way it works in my PCP's practice (in Philly) is that they have a relationship with this mental heath services practice. (I just started with them; they're okay so far, but I don't know enough to give a solid recommendation.)

A therapist from the mental health services practice met with me to do the initial assessment (at my PCP's office), then he set me up with a therapist at their practice. If the therapist and patient decide that medication is the best course of action, it's a separate meeting with their psychiatrist for that.
posted by desuetude at 9:42 AM on August 4, 2010

An interviewee on Fresh Air within the last month discussed that psychiatrists rarely provide therapy now, so I'd proceed on the assumption that you're looking for two providers. (Those interviews are streamable online, and the interviewee had recently written a book, so more information is available if you'd like it. I'd look for it for you, but I am at work. Let me know if you can't find it.)
posted by slidell at 12:32 PM on August 4, 2010

You should also know that many of the limits in your plan may soon change due to relatively recent parity laws (Google MHPAEA,) and that somewhere in your plan's documentation you might have a clause where you can trade inpatient days for outpatient sessions.

And it's ironically good that you're starting this late in the year - between two different docs and just starting treatment, I would expect 20 visits to get you through about 7 months. In the first few months you will see whoever you see far more than you would otherwise - I've seen people go weekly for the first two months. Do not get worried if this happens, it is normal. Same with trying five different drugs before one works well.
posted by SMPA at 12:43 PM on August 4, 2010

I just got out of therapy for anxiety (I felt like I wasn't getting much out of it anymore).

I was seeing a psychiatrist and a licensed clinical social worker. I chose a LCSW because they tend to be more pragmatic, and give more advice, etc., while psychologists tend to follow doctrine. I wasn't a fan of the psychiatrist because I had to see her once/month to follow up on medications and she would do a full counseling session, so I had to repeat myself after talking to my therapist (started out once/week, ended up at once or twice a month). I thought it was stressful repeating myself, and my psychiatrist seemed like more of an intellectual that didn't have much practical knowledge on dealing with anxiety.

If I had to do it again, I'd just get the medication from my physician and see the therapist, and make sure that I'd signed the release allowing my therapist to communicate with my doctor.

Also, here's a really great anxiety workbook, also, that can give you a good view on helping with anxiety (it's flexible and has techniques to help with any type) : http://www.amazon.com/Anxiety-Phobia-Workbook-Fourth/dp/1572244135/ref=sr_1_3?s=books&ie=UTF8&qid=1280948682&sr=1-3
posted by thebeagle at 1:31 PM on August 4, 2010

Thanks to everyone who responded. I called my PCP and they made me an appointment for this week to discuss this specifically. A couple points:

julthumbscrew: The "mental health" vs "serious mental illness" sections have their own inpatient/outpatient categories within them, so I was wondering what the difference was. I realize it's nearly impossible to tell without seeing what I'm seeing.

thebeagle: I like the idea of my doctor prescribing the meds and just going to a therapist. That's a great thing that I'll definitely bring up with my PCP. I actually own that book, but I've found self-help books to be overwhelming, especially when they are that huge. I do read it though.

desuetude: Thanks for the recommendation. They have *amazing* hours. I was worried that I would have to take a lot of time off from work to work on this, which was another issue.

Thanks for the input, and please keep it coming!
posted by your mom's a sock puppet at 1:42 PM on August 4, 2010

I used to do assessments and admissions/referrals for a psychiatric hospital. My advice to you (not medical advice, blah blah blah) is to find mental health services from a counselor (this could be either a LCSW, LPC (Licensed Professional Counselor) or LPE (Licensed Psychological Examiner) or some other combination of letters first. These people can do the full assessment on you and create your treatment plan. They will probably ask about your thoughts on medication, and while they can't prescribe they can discuss whether or not you need to see a psychiatrist (MD who prescribes) for meds. There is no need for you to start with a psychiatrist specifically.

The best setup is to find a counselor who is in a practice with a psychiatrist. Easy to refer and manage your treatment plan together (they usually meet and discuss their shared patients, which is a good thing).

If your PCP works closely with a counselor, or is comfortable with prescribing anti anxiety meds, the PCP can prescribe. You will need to be open and honest about side effects though...psych meds can require quite a few adjustments to get to the right dose. Unless the PCP is really experienced in this, I don't advise getting meds from them for someone who is just starting out on this path. Once you've been on meds for a while and understand the effects and how to monitor how you're doing, they can maintain the prescription with your input. However, once you get the right meds and dosage, a psychiatrist will probably only see you once every 3 or 6 months to check in, so if the costs are the same go with the psychiatrist. Once again, if they share the same practice as your counselor it's easier to communicate and monitor meds.

I'd be prepared with a list of counselors that you are interested in being referred to if your PCP doesn't have a specific practice he/she refers to. Check to see who's in network with your insurance, and check out their websites if possible. I've seen a lot of practices who put their approach to therapy, experience, specializations, etc on the web so it can really help to do your research and see which ones "speak" to you.

Sorry this is long...memail me if you want more advice. I can't speak to your location, but you definitely don't have to go into this blind! Also, general anxiety, especially with life stressors wouldn't qualify as "serious mental illness"...that term is usually reserved for Bipolar Disorder or Schizophrenia or other very long lasting/chronic illnesses. I wouldn't worry about that category right now.
posted by MultiFaceted at 4:34 PM on August 4, 2010

desuetude: Thanks for the recommendation. They have *amazing* hours. I was worried that I would have to take a lot of time off from work to work on this, which was another issue.

FYI, I have IBX too, so I know that this practice is in the network. Memail me if you want some more boring details about their procedure for getting you started, so that you know what to expect.
posted by desuetude at 4:39 PM on August 4, 2010

Hi OP,

Lots of great suggestions so far, and it's great that you're seeking out therapy. I just wanted to chime in with one suggestion:

I see you are looking in Philly. I know that UPenn medical has some top notch doctors doing great research into anxiety...many of the best anxiety specialists in the world work out of UPenn medical.

You should check out the Center for the Treatment and Study of Anxiety. It's associated with UPenn Medical and some of the best anxiety specialists in the world, so it's worth at least checking out!
posted by HabeasCorpus at 6:55 AM on August 5, 2010