by Rachel Conrad, MD, and J. Wesley Boyd, MD, PhD
Imagine being a college student like Alex, who was experiencing increasing anxiety and depression as the academic year progressed. During the spring semester, Alex finally found a psychiatrist in their college town, and after months of waiting, they began treatment and started to feel better. The crushing weight of their symptoms started to lift. But as summer approached, a new hurdle emerged: Alex was heading back home—to a different state—and their psychiatrist wasn’t licensed to practice there.
Meanwhile, their roommate, who was treated for depression during high school and developed a relationship with a psychiatrist at home, was forced to cut ties with their psychiatrist during the risky and vulnerable transition to their first year of college.
This isn’t just Alex’s story. It’s the largely untold reality for many college students who find themselves caught between state lines and bureaucratic red tape in their quest for Mental health care. And the stakes? All too high.
In a paper we have just published in the journal Psychiatric Services, “Alex” tries to find a psychiatrist by contacting psychiatrists via online directory listings and explaining their predicament. We draw the curtain back on an issue that affects countless students who need psychiatric care. Our study reveals that geographical mobility—essentially traveling between home and campus and summer internship and study abroad—often places students like Alex in a precarious position, interrupting care and jeopardizing their Mental health.
Why does this happen? Much of the blame lies with state medical licensure requirements. Under current laws, physicians must hold a license in the state where the patient is located at the specific moment of the telehealth encounter, which restricts the continuity of care for patients who travel across state lines. However, many states offer certain (often confusing) exemptions for specific situations like continuity of care or rare diseases. Increasingly, states also have telehealth registries, which allow physicians with a full medical license in another state to see patients only via telehealth without a medical license in their state. The reality, though, is that few psychiatrists are aware of or even willing to navigate these exemptions or join the telehealth registry.
Using a simulated-patient methodology, we attempted to contact 901 psychiatrists across various states through their listings on a popular website for clinicians to list their practices. We were able to reach only 31 percent of them, and only 16 percent were accepting new patients.
Shockingly, we found that on average nine phone calls were required to reach a psychiatrist who was accepting new patients and in-network for a private health plan. By contrast, 77 phone calls were required to reach a psychiatrist who was accepting new patients and in-network for any Medicaid health plan; and 108 phone calls were required to reach a psychiatrist who was in-network with Medicaid and had initial appointments available in person.
Only five psychiatrists of the 901 who we attempted to contact were aware of the state licensure exemptions and telehealth registries that would allow them to treat patients like Alex across state lines.
Our findings highlight the dramatic difficulties patients face when trying to secure an initial psychiatric appointment, especially when they hope to utilize Medicaid as payment. As such, college-age students can face nearly insurmountable hurdles if they hope to maintain continuity of care as they move from college to home and back again. The system meant to support patients falters because its potential isn’t being fully realized. And the consequence? Students are left high and dry during pivotal times, facing unnecessary breaks in treatment that could lead to setbacks.
On a federal level, a precedent exists for an exception that allows the practice of medicine across state lines without a medical license for continuity of care. In 2018, Congress passed the Sports Medicine Licensure Clarity Act (SMLCA), which allows any physician, clinician, or licensed practitioner traveling with sports teams to practice in any state in order to ensure that athletes have access and continuity of care. Extending such federal licenses to allow continuity of care for students could make all the difference. Imagine a world where Alex doesn’t have to choose between going home for the summer and keeping their Mental health stable. It’s a world within reach if we push for reform.
Our research on the existing state laws, the data we collected about the availability of outpatient psychiatrists, and our policy recommendations are published in a white paper that was commissioned by the Ruderman Family Foundation.
The call to action is simple yet profound. We need improved awareness among psychiatrists and legislative action to ensure exemptions are clear, coherent, and universally applied. Let’s bridge the gap that state lines have created. Alex and many students like them deserve seamless access to Mental health care—regardless of where they might spend their summer.
Our research is more than data; it’s a clarion call for change. Let’s rally for reforms that prioritize Mental health and continuity of care, breaking down the barriers that hinder college students from thriving.
As we return to Alex’s story, it’s crucial to remember that these gaps in care are not just statistical figures. They are real-life challenges faced by real people. Our findings underscore the pressing need for reforms so that students like Alex are never again forced to compromise their mental well-being because of geographical boundaries.
The time for change is now. We need to pave the way for a more accessible Mental health system that respects the needs of our students, transcending state borders and dismantling unnecessary hurdles to needed care. Students like Alex deserve no less.
Rachel Conrad, MD, is a psychiatrist and medical ethicist in the Department of Child and Adolescent Psychiatry, Brattleboro Retreat, Brattleboro, Vermont.
