The average American who develops a mental health condition waits around 11 years before receiving any treatment. This figure has barely changed for many years, despite growing media coverage raising awareness and the expansion of mental health benefits in insurance coverage. Cost, the difficulty in recognizing a problem and stigma all play a part in that delay, but for a great number of people, the obstacle is that they live somewhere where there is a shortage of mental health providers. In these areas, whether someone is able to pay for care matters much less than if there is anyone available to provide it, April Health reports.

This is the unfortunate reality for more than 137 million Americans who live in what the federal government defines as Mental Health Professional Shortage Areas. More than 7,500 communities across the country now fall under that definition, marking where demand for mental health support has outpaced supply and making residents eligible for certain funding and workforce programs. But, what it doesn’t do is place a mental health provider in these areas. It simply confirms what the residents already know, which is that getting an appointment can be difficult and sometimes nearly impossible. The shortage of mental health professionals is also far from evenly distributed, and the areas with the most severe shortages tend to share a similar profile.

The South and rural West areas carry much of the burden, with Mississippi, Alabama and Wyoming consistently ranking among the states with the fewest mental health providers per person, and some counties within these areas having no practicing psychiatrist at all. Texas stands out as a particularly grim example of this, as despite having one of the largest healthcare systems in the U.S., it contains some of the most underserved areas anywhere in the country. In the western part of the state and the Panhandle, the nearest psychiatrist can be a two- or three-hour drive away, which becomes a real obstacle for anyone without reliable transport or the ability to take time off work.

Across much of Appalachia, communities in Kentucky, West Virginia and Tennessee have experienced decades of economic decline and the effects of the opioid epidemic and also rank among the most underserved areas for access to mental health care. These pressures have an impact on one another, as the same conditions that cause higher rates of depression, anxiety and substance use disorders exist alongside a limited supply of clinicians able to treat them. Over time it snowballs, with more and more people needing support and still almost no one available to treat them.

The problem is not restricted to just rural regions or lower-income states, though. There are also significant shortages within some of the wealthiest states in the country, including California, Illinois and New York. In cities such as Chicago, Los Angeles and New York, you tend to find providers clustered in the more affluent ZIP codes, and they grow scarcer as you reach the lower-income areas. Across nearly every state in the country, wealth and the availability of care are closely linked, leaving the communities with the least resources with the fewest options for mental health treatment.

Insurers typically reimburse mental health services at lower rates than for physical health care, which makes it difficult to sustain a practice where many patients depend on their insurance for treatment or cannot afford to pay out of pocket. The Mental Health Parity and Addiction Equity Act was created to address this issue by requiring insurers to cover mental health on equal terms with physical health, although enforcement of this has been inconsistent.

For many people in these areas, the first step is a visit to their usual primary care provider, who refers them to a specialist. The first one they try won’t have spaces anytime soon, the next isn’t taking on new patients, and this goes on until they find that the nearest place with availability is hours away, so they decide not to bother. The referral from their primary care provider is logged in the system, but the fact that they never make it to seeing a specialist isn’t. Left untreated, the condition gets worse, and it is usually family and friends who see it worsening, until the only place left to turn is the emergency room.

Federal programs have been introduced to try to drive more graduates towards the places that need them, most notably through the National Health Service Corps, which repays student loans for clinicians who commit to working in one of the areas defined as a Mental Health Professional Shortage Area for a set number of years. Although these programs have placed thousands of providers in the underserved communities, the scale of the gap is far larger than the scale of the incentives, and once they have served their commitment, many participants move on, and while the program is making small improvements to the system, it is still not fixing the issue.

Technology has helped in a way, seeing as a video appointment can replace a long drive for people who have a good internet connection. The counties with the fewest providers, however, are also the ones with the weakest broadband connections or access to broadband at all. Historically, state licensing laws have stopped providers from being able to treat patients from across state lines, which limits how much a well-served state can help others. To bypass this, states have introduced interstate licensing agreements, allowing psychologists to practice across the participating states, which most states have now signed up to. Once again, these arrangements do not create new providers; they simply change how far the existing workforce can be stretched.

Some primary care practices have approached the problem from a different angle, by building mental health support into the care they are already delivering so that patients don’t have to join a specialist waitlist. One of these is the Collaborative Care Model, which introduces a care manager and a consulting psychiatrist into the patient’s care alongside their usual primary care provider.

America's mental health care deserts have been mapped and tracked for years, so their locations are not a mystery. Recently, however, there has been an increase in tools that work around the distance rather than waiting for the workforce issue to be resolved, but for that 11-year wait to start coming down, there would have to be enough workforce to meet the demand across every shortage area. Until then, the person who decided not to bother after their search ended at a dead end is likely still struggling, and may not try reaching out for help again. The biggest barrier to receiving mental health support in America remains where a person happens to live.

This story was produced by April Health and reviewed and distributed by Stacker.