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Massachusetts requires health insurance for all, is second in the nation in the number of doctors per capita, and mandates equal coverage for mental and physical illnesses. Yet when researchers there posed as well-insured patients seeking treatment for depression, only 6% of calls to mental health facilities resulted in an appointment within two weeks, according to a new study.

This was true even though the prospective "patients" claimed that they'd been told by an emergency room doctor to seek psychiatric care within that time period — so those who took the calls should have been alert to the possibility that the patients were suicidal or otherwise needed urgent care. "What this study says is that even with what is basically the best private insurance available in this state and [probably] in many others as well, help is very difficult to find and may be impossible to find for many," says Steffie Woolhandler, visiting professor of medicine at Harvard Medical School and an author of the study. MORE:

The research, which was published in the Annals of Emergency Medicine, found that nearly a quarter of the calls made were never returned—even after the "patient" called again to follow up. Another 23% of providers turned people away if they were not already patients of a primary care physician associated with their institution. Only 12% of the facilities actually offered appointments to the patients.

"I think a lot of systems are trying to cut back on psychiatric care, but they don't want to cut back to zero, so they restrict access to the handful of appointments that they have to people who are already part of their system," says Woolhandler.

Since depression itself can make help-seeking difficult because it reduces motivation and makes people feel hopeless, even small barriers to care can have a huge impact. "How many seriously depressed people are going to persevere through all of this to get an appointment?" Woolhandler asks.

The research was prompted by concerns raised by psychiatric residents, who were interested in access to mental health care. They had the sense that when they sent people home from the emergency room, they weren't actually getting the follow-up care that had been recommended. MORE:

So for the study, researchers posed as patients in exactly that situation, saying they had Blue Cross/Blue Shield insurance, which is held by about half of all Massachusetts citizens and is considered to provide excellent coverage. All of the facilities they called were listed as preferred providers of care for BC/BS members, yet only 12% offered appointments.

"Having to suffer longer with depression is very painful and to expose people unnecessarily to prolonged suffer is really not acceptable when we have the resources to help people with this problem," says Woolhandler.

Since this study only looked at what is basically the best-case scenario in the state that has an insurance system similar to the one that will be rolled out nationwide under President Obama's Patient Protection and Affordable Care Act, it suggests that simply providing insurance will not be enough to make mental health care appropriately accessible to patients in need. Truly effective mental health care requires both coverage and ability to get services. MORE:

• MAIA SZALAVITZ