Early detection, we are told, is wise. We believe it opens doors to treatment, better outcomes, fewer sick days, more productivity, less bankruptcy, more stable lives and families, and even suicide prevention. That's why all primary care doctors, a gateway to treatment, are supposed be on the look out for signs of depression or symptoms of bipolar disorder.

Sounds simple. But it doesn't always work that way.

Physician shortages is the disturbing problem raised by a new study appearing in Health Affairs.Nearly two-thirds of a sample of primary-care physicians (n=6,600) say their patients cannot find mental health services. This was most acute in remote, poor and/or rural communities. And pediatricians everywhere were least likely to find psychiatrists.

A two-tiered insurance system, clearly discriminatory, markedly hindered access to care. Ironically, communities with higher concentrations of HMOs have more service barriers. Basically it led to higher costs and less treatment, both of which curtailed access. Passage of the Wellstone-Domenici mental health parity law last year tried to address this inequity in funding and access. By calling their study "Beyond Parity," the authors are asking about long lines getting longer because services are not in place.

According to the American Psychiatric Association, 38,000 psychiatrists stretch to meet America's mental health needs. Last year's report from Health Resources and Services Administration (HRSA) found 77 million Americans live in areas officially designated "shortage areas" for mental health. It was estimated that an additional 5,45 practitioners would be needed to bring the ratio to one psychiatrist for every 10,000 people.

Some states are harder hit than others. In Nebraska, all but five counties qualify as official shortage areas. To address this locally, lawmakers in Nebraska introduced a bill to increase the mental health workforce (including telehealth network), reports the Journal Star.

Shouldn't this be a national concern? All of medicine face physician shortages. These can be anticipated by looking at post-graduate training programs. For psychiatry, although this year was better than last, according to the data collected by the Accreditation Council of Graduate Medical Education, the dearth of applicants meant that 31 percent of the trainees came from international medical schools. In previous years, the numbers were even more discouraging.

Appalling gap for children
A similar shortage in training professionals exists for children with mental health needs. A decade ago, Surgeon General David Satcher reported that only one youngster in five with an emotional problem received health services. Today the nation's 7,000 child psychiatrists are disproportionately located in New England or along the Pacific coast with a sprinkling in the mid-west. Training at the current rate of about 600 new residents a year will not grow the numbers, which The American Association of Child and Adolescent Psychiatrists estimates should be closer to 12,000.

Recently Rep. Patrick Kennedy (D-RI) introduced a bill (HR 1932) to expand the work force for helping youngsters. It calls for a federal loan repayment program and scholarships to recruit mental health professionals to work with children. Kennedy has introduced this bill four times since 2001, but Republican controlled committees stalled it, even in 109th Congress when there were 71 co-sponsors.

The authors of "Beyond Parity" argue that the experiences of primary care physicians "provide unique insights into the limitations of the mental health care system." Some might argue that they are a siren call to the limitations of health delivery which has segregated "mental health care" from "health care." Continuing to think about them as two systems will not result in the necessary integration which should be the goal. To move this agenda, the Whole Health Campaign - a coalition of 106 organizations - formulated a strategy for a health delivery system to meet these shortcomings. It was delivered to the Obama transition team last year.

Now that a new secretary is about to lead the department of Health and Human Services, we should wait no longer to move beyond parity.