Addressing Social and Systemic Barriers in Schizophrenia

Announcer:
You’re listening to On the Frontlines of Schizophrenia on ReachMD. And now, here’s your host, Dr. Shelina Ramnarine.

Dr. Ramnarine: 
This is On the Frontlines of Schizophrenia on ReachMD, and I'm Dr. Shelina Ramnarine. Joining me to discuss access gaps in schizophrenia care and what we can do to close them is Dr. Margaret Emerson. She's a Clinical Associate Professor and a board-certified Advanced Practice Psychiatric Nurse Practitioner at the University of Nebraska Medical Center in Omaha.

Dr. Emerson, welcome to the program.

Dr. Emerson:
Thanks so much for having me. Excited to be here.

Dr. Ramnarine:
So let's start with the bigger picture, Dr. Emerson. What are some of the main access barriers that underserved populations face when it comes to psychiatric treatment?

Dr. Emerson:
So, when we zoom out and look at the big picture, the barriers are really layered. At the most basic level, cost and insurance coverage are huge obstacles for individuals. And many people are either underinsured or uninsured, or they face some of these high out-of-pocket expenses for mental health care.

And then on top of that, there is a significant shortage of psychiatric providers, especially in the rural areas or the underserved urban areas, which means, a lot of times, long wait times for individuals to get even just the initial appointment. One of the things that people sometimes don't consider is the idea of transportation, which can be a huge obstacle for individuals. So if you can't reliably get to a clinic, continuity of care becomes almost impossible.

And then there's this idea of stigma, which really plays a powerful role. So, in many communities, seeking psychiatric care is still associated with the ideas of shame or mistrust of the medical system. And so those are things that we have to consider.

And then there's also just structural barriers; the complicated referral process that we often ask individuals to go through, limited clinic hours, or lack of language access can be subtle things that, really, still effectively shut people out of care altogether.

Dr. Ramnarine:
Let's zero in now on schizophrenia. Can you walk us through the unique challenges that these patients face when trying to access consistent and high-quality psychiatric care?

Dr. Emerson:
Sure. So schizophrenia brings a unique and often more complex set of challenges. One of the biggest things that we can see is just some of the nature of the illness itself; symptoms that individuals may experience are some difficulties with insight, some cognitive impairments, and they might have paranoia or disorganized thinking. And so that can make it really hard for patients to recognize that they need care or trust providers once they're actually in the system.

I think consistency is another major hurdle. Schizophrenia often requires longer-term treatment, and definitely coordinated treatment. That includes items like medication management, therapy, and social support. But fragmented health systems make it hard to sustain some of those things that need to really occur for those individuals. So what we see is that individuals may have missed appointments or medication non-adherence, and frequent hospitalizations occur more often than we'd like to. And it's not an indication that patients don't care. It's really because the system isn't designed, oftentimes, to meet them where they're at.

Then there's also this aspect of social instability. We see higher rates of homelessness, unemployment, and involvement with the justice system with individuals with schizophrenia. So that becomes a clear path to impacting their ability to have high-quality care. So it's not just a medical issue; it's deeply tied to some of those social and structural factors as well.

Dr. Ramnarine:
Yeah, it sounds very layered. For those just tuning in, you're listening to On the Frontlines of Schizophrenia on ReachMD. I'm Dr. Shelina Ramnarine, and I'm speaking with Dr. Margaret Emerson about improving care for underserved populations living with schizophrenia.

Dr. Emerson, now that we've discussed some barriers to care, let's focus on how we can overcome them. So what models or innovations are showing the most promise in bridging these gouts?

Dr. Emerson:
I think that's a great question, and there's actually a lot of optimism here in this area. So one promising approach that I am involved with oftentimes is integrated care models, where mental health services are embedded within primary care or community clinics. This really helps to address some of those factors of stigma. It simplifies access and allows for earlier intervention. So those are one of the successes that we see.

There's also a sort of community treatment, or what we call ACT Teams, and those show strong outcomes for people with serious mental illness like schizophrenia. And these are multidisciplinary teams that go out into the community rather than expecting patients to come to the clinic, which can be a game changer for a lot of folks to improve some of that engagement and continuity.

And then we see telepsychiatry has significantly expanded access for people that are in rural or underserved areas, because it addresses that issue with transportation barriers and allows to shorten some of the wait times. So we can connect with patients in their homes and in their trusted community and make a difference by getting care without having to go somewhere else for it.

And then there is this idea of digital tools. That is another passion of mine, where we can really support ongoing engagement. So things like mobile applications for medication reminders, symptom tracking, and some of the secure messaging care pathways have been effective. And then these tools are especially helpful for patients with serious mental illness, because it allows us to have some of that consistency and early identification of symptoms, which is critical.

Dr. Ramnarine:
So there's also growing attention on social determinants of health. How can addressing factors like housing, transportation, or food insecurity improve psychiatric treatment outcomes?

Dr. Emerson:
So, again, a great question. I think it's so important that if we address social determinants of health, this isn't something extra—it's foundational to being able to meet the needs of individuals. If someone doesn't have stable housing, it's incredibly difficult to ask them to prioritize taking their medications, keeping appointments, or even have the idea of focusing on recovery, because that really isn't that hierarchy of needs that they're focusing on.

Housing instability alone is associated with higher hospitalization rates and poor psychiatric outcomes. And things like transportation affects, obviously, whether a person can show up for care. So not having the ability to access that or the financial needs to even pay for a bus fare to get to a clinic is an increasingly challenging barrier.

Food insecurity impacts physical health, cognitive functioning, and medication tolerance. So when we address these needs through housing support and transportation assistance or partnerships with the community organizations, we're going to ultimately see better engagement, fewer crises, and more sustained recovery, for sure.

So, in many ways, meeting the basic needs creates the conditions where psychiatric treatment can actually work, which is what we want to see.

Dr. Ramnarine:
That makes sense. And in addition, how important is it for care teams to consider cultural competency and community trust when treating underserved populations?

Dr. Emerson:

Gosh, you know, it's absolutely critical. So cultural competency isn't just about, I think, the idea of language. It's really understanding the values, beliefs, and historical trauma or experiences that people may have had with the healthcare system. So there are a lot of underserved communities that have very real reasons for feeling ideas of mistrust that might be rooted in very legitimate feelings of discrimination or harm.

So we need to take notice that individuals may be coming to us with these underlying feelings that are not easily amended just by interactions with them. When care teams take the time to really listen, respect their cultural perspectives, and involve families and community leaders when we can, treatment becomes far more effective, because it demonstrates that we can establish an idea of understanding and trust.

So, ultimately, that leads us to improving their treatment adherence. We have these open dialogues and we see longer-term engagement. We want to create this common understanding that psychiatric care isn't something that we do to patients. It's something that we build with them, and trust really is the foundation of that relationship.

Dr. Ramnarine:
That's a great sentiment. So, as we come to the end of our program, Dr. Emerson, is there anything that we didn't discuss that you'd like to leave our audience with?

Dr. Emerson:
I’d just like to leave listeners with this thought that access to psychiatric care really goes far beyond medicine. It really speaks to who we are as a society and how we care for one another. When we really design systems that work for the most vulnerable among us, it is going to benefit all of us. And progress doesn't require one massive solution; it really happens through partnerships, innovation, compassion, and this willingness to rethink how and where care is delivered. So if it happens in a way that is inclusively responsive to the voices and lived experience of people with the individuals we're trying to serve, ultimately, we're going to see those benefits translate in a way that's sustainable. There's still a lot of work to do, but there's also some real momentum, and that's something worth holding onto.

Dr. Ramnarine:
With those final thoughts in mind, I would like to thank my guest, Dr. Margaret Emerson, for joining me to discuss how we can improve access and outcomes for underserved populations with schizophrenia. Dr. Emerson, thanks so much for joining us today.

Dr. Emerson:
Thank you so much for having me.

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