“We want to be heard”: A Qualitative Study of Mental Health Care Access among Patients of an Urban Federally Qualified Health Center

Abstract

Introduction.

Although depression is common in primary care, challenges to timely intervention exist, particularly for communities of color and lower socioeconomic status. Our objective was to understand barriers and facilitators to mental healthcare access among a sample of patients receiving care at a federally qualified health center (FQHC) in Minnesota, United States.

Methods.

We qualitatively interviewed 34 patients of an urban FQHC, purposively sampled on race/ethnicity, insurance status, language, and depression symptom status (based on Patient Health Questionnaire-9 responses). We inductively and deductively analyzed interview data, leveraging theory in both the codebook development and analysis processes.

Results.

Participants, who were predominantly English-speaking, female, not privately insured, and people of color, shared numerous barriers and facilitators to accessing mental healthcare. Prominent barriers primarily concerned healthcare providers, including perceived dismissal of mental health concerns and challenges with provider continuity. Additional barriers included the costs of mental health care, communication breakdowns, the patient portal, and community-specific perceptions of mental health. Prominent facilitators included clinic organizational factors (internal and external) and staff friendliness and warmth. Other factors including consideration of patients’ financial situation, integrated management of behavioral and physical health conditions, language concordant staff, the telehealth visit modality, and the clinic’s social mission were also raised as facilitating access.

Conclusion.

Patient voices from a single FQHC illustrate the challenges and possibilities of providing mental healthcare in safety net settings. Clinical, strategy, and policy solutions can be tailored to minimize barriers and optimize facilitators documented herein.

Introduction

Depression is prevalent and disproportionately impacts communities of color and low socioeconomic status.^1,2 Although depression can be managed with appropriate pharmacologic and psychotherapeutic interventions, many people are delayed to care due to numerous factors including perceptions of mental illness, financial barriers, or limited access to appropriate providers.^3–5 For certain Black, Indigenous, and People of Color (BIPOC) communities, these barriers may be further exacerbated by legacies of structural racism and stigma within healthcare.⁶

Delays in care can result in social and functional impairment for patients and complicate the management of comorbid physical conditions. These consequences yield significant human and financial costs, highlighting the need for greater insight into pathways to promote uptake of services. Federally qualified health centers (FQHCs) might represent an optimal location for the identification and management of behavioral health disorders such as depression.^7–9 FQHCs are community-based clinics that provide outpatient services for underserved regions (e.g., health professions shortage areas) or populations (e.g., people experiencing homelessness). FQHCs receive federal funding support to carry out their work, and core to the FQHC designation are mandates that clinics offer sliding-scale payment options, enabling services (e.g., transportation support), and patient representation on governing boards. As more than half of adults with a mental health or substance use disorder will not receive care from a behavioral health specialist (e.g., psychotherapist, psychiatrist), the provision of assessment, diagnosis, and treatment within primary care contexts is crucial.¹⁰

Prior studies have demonstrated the potential for FQHCs to deliver evidence-based treatment addressing mental health conditions for underserved groups, such as rural¹¹ or racial/ethnic minority communities.^12–13 To further clarify opportunities for safety net clinics to support mental healthcare access, we undertook a study to understand barriers and facilitators to receiving mental healthcare from the perspectives of FQHC patients.

Methods

Study setting

This qualitative study took place at an urban FQHC in a predominantly racial/ethnic minority neighborhood.^14–15 Despite significant cultural and community strengths, the neighborhood has also been subject to inequitable policies and economic disinvestment.¹⁶ As such, the neighborhood is impacted by health disparities, such as higher cancer incidence,¹⁷ disproportionate chronic diseases such as heart disease and asthma,^18,19 as well as maternal-child health (e.g., preterm birth^20,21) and mental health conditions.

In 2020, FQHC leadership took an interest in depression care quality after two local hospital needs assessments identified mental health as a key objective.^22,23 Thus, a qualitative approach was deemed relevant for exploring patients’ perspectives on access in the initial phase. We selected phone-based interviews to gather data on a sensitive topic in a physically distanced manner during the COVID-19 pandemic.

Study sample

The sampling frame was generated from the FQHC’s electronic health record employing inclusion and exclusion criteria. Per guidelines from Minnesota Community Measurement,²⁴ patients who had been seen at the FQHC ≥1 time in 2020 with diagnoses of major, persistent (dysthymia), or unspecified depressive disorder were included, based on International Classification of Diseases, 10^th Edition (ICD-10) codes. Those with bipolar, psychotic, or pervasive developmental disorders were excluded, as were patients receiving palliative care. This process yielded a total sample of 906 eligible patients.

Among eligible patients, we purposively sampled²⁵ patients based on depression remission status (remission vs. not in remission at 6 or 12 months, based on Patient Health Questionnaire-9 score cutoff of >9),²⁴ race/ethnicity (White, Black, Hispanic/Latinx, Other), and insurance status (commercial, public, and self-pay/sliding scale). We intentionally sampled for demographic, socioeconomic, and symptomatic variability to limit selection biases. No additional sociodemographic information was collected beyond the aforementioned variables, which were was accessible from the electronic health record.

Data collection

We developed a semi-structured interview guide based on the Behavioral Model for Vulnerable Populations.²⁶ The interview guide was pilot-tested with two patients reflecting the target population, leading to two revisions to enhance clarity and succinctness. The guide was also translated into Spanish and reviewed by a trained medical interpreter, using a forward and backward-translation approach.²⁷

In 2021, mso2 M.S. conducted private, recorded interviews over telephone (Figure 1). No financial compensation was offered, and patients were assured that information disclosed would not be personally linked to them or influence their care. Interviews were conducted in English or Spanish and lasted between 20–45 minutes; patients who spoke neither language were excluded at this phase (n=4). All patients who did not pick up received a voicemail, and were called at least one more time. Ultimately, 118 patients were contacted to achieve theoretical saturation.²⁵ We excluded 47 patients due to not picking up after two voicemails; 19 due to non-functional or full voicemail; and 18 due to time, privacy, or discomfort reasons. This process resulted in a final sample of 34 interviewees. During interviews, mso2 M.S. took rapid thematic notes²⁸ using a pre-designed matrix (available upon request).

Figure 1.

Workflow used to conduct outreach interviews within a qualitative assessment of patients’ experiences with mental healthcare access in an urban federally qualified health center – Minnesota, 2021

Data Analysis

Interview audio recordings were transcribed and analyzed in tandem with rapid thematic notes contemporaneously to ongoing data collection. First, a phenomenological approach was employed to understand participants’ responses without preconceptions to develop a working model of ideas shared. Both the frequency of concept mentions and their representation across interviewees provided an indicator of the concept’s salience. Salient concepts were articulated as an overarching theme with an accompanying description. Subsequently, a deductive lens was applied in which participant responses were situated within the “depression treatment cascade in primary care” model,²⁹ which proposes that patients proceed through a continuum of care from community-based prevalence of depression to clinical recognition, provision of treatment, treatment adequacy, and symptom remission. Responses were classified into each of these phases of the care continuum, and analysts’ observations of emergent phases, allowed them to iteratively return to the primary transcripts to scan for less represented phases. This balanced inductive-deductive approach allowed us to understand participant viewpoints systematically while limiting analyst bias. Analyses were carried out by mso2 M.S. a Spanish-speaking medical student, and mso2 J.M. a Spanish-speaking graduate sociology student. mso2 M.S. was completing clinical rotations with the FQHC during the study,^a and mso2 J.M. was unaffiliated although was previously a FQHC patient. The two-member team approach permitted us to double-code all interviews, triangulate findings across independent observers, and enhance confidence in themes witnessed. All Spanish-language interviews were retained in the original language throughout analysis to optimize fidelity to participants’ intended meaning, and were confirmed by mso2 M.H. (a native Spanish-speaker).²⁷ An audit trail was recorded allowing us to track analytic decisions and memos throughout. As an informal member check procedure, findings were shared with the FQHC’s quality improvement and behavioral health teams to discuss the extent to which findings reflected staff’s perception of mental healthcare access issues.

Data were analyzed manually, with coding and theme identification facilitated by Microsoft Word (Redmond, WA). The University of Minnesota Institutional Review Board deemed the study “not research involving human subjects”.

Results

Participant characteristics

The 34 interviewees were approximately one-third Black (32.4%) and White (29.4%), one-quarter Hispanic/Latinx (23.5%), and 15% classified as Other.^b The majority were English-speaking (79.4%) with the remaining fifth Spanish-speaking. More than 4/5 of respondents identified as female. Only three (8.8%) were commercially insured, with the remainder comprising those on public insurance (Medicaid [44.1%] or Medicare [17.6%]) and who paid out-of-pocket (32.4%).

Regarding participants’ depression status, 12 (35.2%) were currently in remission at 6 or 12 months post-index assessment whereas 22 (64.7%) were currently not in remission. In addition, among the 34 individuals, seven (20.6%) were scheduled for follow-up appointments following the interview (Table 1). For five individuals (14.7%), discrepancies or issues were able to be addressed through contacting the patient (e.g., following-up on a prior referral).

Table 1.

Descriptive statistics of participants in a qualitative assessment of patients’ experiences with mental healthcare access in an urban federally qualified health center – Minnesota, 2021

	N	%
Status of Depression a
Remission at 6 months	2	5.9
Not in remission at 6 months	8	23.5
Remission at 12 months	10	29.4
Not in remission at 12 months	14	41.2
Gender
Female	28	82.4
Male	6	17.6
Race/Ethnicity
White, non-Hispanic	10	29.4
African American, non-Hispanic	11	32.4
Hispanic/Latinx	8	23.5
Other b	5	14.7
Language
English	27	79.4
Spanish	7	20.6
Insurance Type
Commercial	3	8.8
Medicaid (including Minnesota Medical Assistance)	15	44.1
Medicare	6	17.6
Self-Pay or Sliding Fee Scale	11	32.4
Total	34	100.0

^aBased on Patient Health Questionnaire-9 score of ≤9 (in remission) vs. >9 (not in remission).

^bIncludes patients who did not disclose their race/ethnicity or who identified as Asian or American Indian/Alaska Native; these were combined into one category to protect the confidentiality of individual patients.

Themes

Thematic findings are described narratively below sorted into barriers and facilitators, with illustrative patient quotes integrated throughout (Figure 2).

Figure 2.

Salient facilitators and barriers to mental healthcare access within a qualitative assessment of patients’ experiences with mental healthcare access in an urban federally qualified health center – Minnesota, 2021

Note. Boldface: Themes that emerged with greater relative frequency and representation relative to other salient themes.

Barriers to mental healthcare.

The most prominent barriers pertained to challenges with providers, spanning both medical and behavioral health providers. Although the care provided by these clinicians was often praised (see Facilitators section below), the positive attributes were at times coupled with perceived challenges. First, several interviewees shared experiences where they felt dismissed or “blown off” by providers about mental health concerns; one shared that, “I like my doctor but I don’t think she really listens to me. I think I might go find another doctor that might at least hear me out” (Patient #7, White female). Another mentioned, “the only time I’m concerned is when I say something and they don’t know what to do. They’re trying to tell me about what I have, but sometimes I have other anxiety symptoms they don’t understand” (Patient #1, Latinx female). One patient noted, “I just feel like the doctors need to listen…when we make an appointment at the hospital or clinic, we want to be heard” (Patient #2, Black female).

Several interviewees underscored the importance of provider continuity in providing appropriate mental health services, and the challenges that emerged when continuity was compromised. As Patient #34 (Latinx female) shared, “It is important to have the same provider. To talk about my anxiety meds, yes, I like talking to the same provider because they’ve been there for the whole ride. Even though I know another provider can look at the previous charts, it’s not quite the same”. One interviewee felt that she had been “bounced around”, as her provider was only available two days a week, making it more difficult to see them consistently. She explained, “With ongoing health things, consistency is super important as far as providers, because communication isn’t always so good between providers” (Patient #13, White female).

In addition to provider-related barriers, several respondents also shared concerns about the cost of medications and therapy, particularly if they lacked insurance or were underinsured. One shared that “many of us are wondering ‘how much is this going to cost?’” (Patient #12, Other female), which influenced how often she would come in to clinic. Patient #16 (Black female) shared, “therapy is not cheap, which is partially why I haven’t done it myself. It feels kind of like a bonus.” A third patient’s comment spoke to the issue of being underinsured to easily access needed care, stating:

I wish they could work with us a little more. And I understand that the medical and behavioral health services are costly…But I don’t qualify for sliding scale. I wish they would make it more accessible, because if I had more, I’d pay more. But then to tell me I don’t qualify for the sliding fee, that is rough. I have Medicare through my employer, but my deductible is $7000 a year. – Patient #11, Black female

Communication issues also emerged. Some respondents perceived communication breakdowns between the FQHC and external agencies for additional mental health work-up and management (e.g., psychiatric specialists, psychotherapists) as well as between the FQHC and patients (e.g., “I didn’t know when they accepted people during COVID…They could’ve told me what to expect” [Patient #25, White female]). One interviewee aptly noted that “based on my last experience there’s not really good communication between [the FQHC] and outside agencies.” (Patient #13, White female).

Another area of difficulty was the clinic’s patient portal. Some patients shared issues with accessing their health information, as stated by Patient #1 (Latinx female), “my only concern is [patient portal name]. That is so hard to get in, I have tried so many times, they tried to help me, and that’s really good that they tried to help me...I cannot see anything...And I was like I just give up already.” Another patient expressed hesitation about confidentiality, sharing that “I’m still apprehensive about using it for a lot of things because a lot of that stuff is personal. I don’t necessarily trust the internet…I’m surprised that it stays as safe as it does.” (Patient #6, White male).

The final salient barrier was community perceptions of mental health. Two participants explicitly mentioned the term “stigma” within their self-described Latinx (Patient #15) and Black community (Patient #3), which limited whether people would be likely to seek support for their symptoms. Patient #15 explained that “outreach or community partnerships” could help demystify and normalize the topic, for example, “if they went to grocery stores and put-up flyers about mental wellness or therapy resources”. Another respondent expanded,

I think in the Black community you gotta recognize that people have a lot of distrust for what went down in this country. What still goes down in this country. We all have stories. We all know people that have been treated differently due to skin color. And then when it comes to our emotional state, we want to talk about praying and spirituality. God’s there, I know that, but He wants us to help ourselves too. – Patient #26, Black female

Facilitators to mental healthcare.

Despite challenges, many people interviewed expressed satisfaction and shared factors that positively affected their receipt of mental healthcare. Several noted that they were generally satisfied with their care, offering no specific areas of dissatisfaction (e.g., “My experience has been good. I don’t have any notable things to say” [Patient #12, Other female], “It’s high-quality care”, [Patient #26, White male]).

Among those who articulated specific feedback, the most salient facilitators were factors related to clinic organization and clinical staff. Many respondents expressed that the clinic had a “smooth process”, was “efficient”, “easy”, or was “pretty well laid out” regarding interactions both internal to the physical clinic as well as external processes (e.g., appointment scheduling). Relatedly, several noted that they found “calls or texts to remind [them] about appointments” helpful for ensuring routine follow-up assessment and visits were completed.

Another commonly mentioned facilitator was the friendliness and warmth of staff, with receptionist and laboratory staff garnering numerous commendations. With regard to providers, patients also noted positive connections with both counselors and medical providers, with Patient #8 (Black female) describing her provider as “just like family”.

Many respondents explicitly described how the FQHC attended to their financial situation. As described by one interviewee, “I feel like they were really helpful just around like providing support for care that was based on income. I think I had a lapse in healthcare coverage, and they were able to help cover that” [Patient #10, White male]. Another recounted her positive experience using the clinic’s sliding scale option in the past when she had more limited income. Reflecting on her story, she went on,

I think there’s misconceptions like it’s hard to go to the doctor, or I’m going to have a huge bill, it’s going to be really expensive to see a counselor. Like people don’t know. I tell a lot of people about [FQHC]. And no one has ever mentioned the sliding scale, maybe more people need to know about that. I could literally only pay $19 back then and that was okay. – Patient #4, Latinx female

Another frequent facilitator was the ability for providers that were already seeing patients for chronic health concerns to address patients’ behavioral health as well. In certain cases, providers were able to help patients appreciate their interconnectedness, as shared by one person,

I had been having a lot of tension in my neck, and many episodes of waking up in the night crying and sobbing. I couldn’t shake the memory of what happened to my grandchildren. I had been seeing pictures of them looking so frail and thin in Mexico and it gave me so much pain. [Provider] suggested that I could maybe go see a therapist, which I had never considered before. - Patient #15, Latinx female

Similarly, another interviewee recounted,

I think it was cool that after being with [provider] for like, 4 years, one day she was like, tell me about this survey. It was that survey that asks you about how your energy and mood was doing…We’ve only really talked about my blood pressure and back problems, but I didn’t know my doctor could also talk about my mood. I thought that was totally separate. And you know, working on my mood has helped me with blood pressure and cholesterol meds too. Because I realized there was a shred of me that didn’t feel like this body - my body - was worth preserving. – Patient #17, Black female

Some interviewees expressed that having providers and interpreters that could speak their preferred language (in this case Spanish) was also important. One interviewee took this concept even further, recommending,

Maybe it would be good to [have] therapists that speak Spanish at [the FQHC]. Doing therapy with an interpreter sounded difficult for me and I never wanted my struggles to be broadcast to too many people. Actually, they should speak Spanish and also ideally be Latino themselves. – Patient #5, Latinx female

Some people who had participated in telehealth-based visits, made possible during the COVID-19 pandemic, had positive perceptions of their experience. Many noted it helped them access mental health services more conveniently through saving time (e.g., “It’s not the travel time to and from plus all of that”, [Patient #24, Latinx female]). One interviewee shared, “it can take a couple weeks before I can meet with the doctor. It’s actually really good that we could do it by phone, because I wasn’t feeling any better and needed to adjust my depression medicine” (Patient #31, White female). Another cited that telehealth availability at a behavioral health organization she was referred to “worked really well with [her] work schedule” (Patient #15, Latinx female).

Finally, multiple respondents expressed appreciation for the organization’s social mission, though not solely with respect to mental healthcare. One noted “it’s great that it supports immigrant populations. I am a Latina woman, so I think it’s great that the clinic, inherently in its DNA…serves many populations and that we can talk in Spanish...” (Patient #34, Latinx female). This concept was also well captured by Patient #13 (White female), “I appreciate what you all do for the community, especially people like me that might not have anywhere else to go to.”

Discussion

This study leveraged in-depth interviews among FQHC patients with a history of depression to document beneficial and challenging factors influencing the receipt of mental healthcare. In light of ongoing investments into behavioral health integration within FQHCs and other federally funded organizations,¹³ this work offers timely insights that may assist other clinics in addressing the mental health needs of under-resourced patients.

Among numerous barriers patients endorsed, provider-side issues emerged with prominence, specifically their affective and clinical responses to mental health issues along with challenges in continuity. Primary care provider dismissal, stigma, and other negative responses towards mental health disorders has been documented, particularly for psychotic moreso than mood disorders.³⁰ This finding underscores the importance of behavioral health educational activities within primary care training, which have been documented across levels of training and merit greater attention.^31,32 Conversely, greater incorporation of behavioral health providers (e.g., clinical psychologists) into primary care can support continuity through enhanced interdisciplinary collaboration and reducing stigma by availing services in familiar settings.^5,33

Relatedly, several participants expressed provider continuity challenges negatively influenced their receipt of depression care. Continuity is a cornerstone of community-oriented primary care, and though it is typically discussed with respect to chronic physical health conditions (e.g., diabetes), patient voices illustrate its importance for mental health as well. Practice innovations such as empaneling patients to consistent healthcare teams, advance visit planning, patient-centered appointment scheduling,³⁴ and telemental health strategies can be deployed to increase opportunities for continuity.

Other reported factors included experiences progressing through the clinic’s external and internal workflows, such as referrals for specialty psychiatric services or comments on the clinic’s patient portal. Although patient portals can be valuable tools, there are disparities in patient portal use for communities of color and low-income.³⁵ Efforts to understand and improve the patient portal user experience in FQHCs could increase care engagement and overcome this dimension of primary care inequity.

Importantly, some facilitating factors that emerged in the study reflect attributes inherent to the FQHC model of care. Language concordant service providers, addressing patients’ individual financial situations, and the clinic’s mission to serve regardless of ability to pay were noticed by patients and deemed helpful. As such, our findings highlight the role of FQHCs as key sites for mental health care while suggesting that greater investment into these strategies within primary care writ large could further broaden access.^11–13 Ultimately, findings speak to the value of attending to multi-level factors that influence delivery of services across organizational levels through an implementation science lens.^11,36 Addressing one level alone will likely be sufficient to completely overcome noted barriers, but a multi-pronged approach may assist a broader range of patients in receiving needed services.²⁹ Of note, the extent to which factors we observed affect access may vary across contexts. For example, this study’s dominant barriers primarily concerned provider factors whereas clinics in other settings (e.g., rural communities) might reveal other challenges, such as specialist access.¹¹

Limitations and Strengths

Despite this study’s strengths including theoretical and analyst triangulation, it has limitations. First, we focused our sample on only those with depressive disorders, thereby excluding patients classified with relevant but distinct ICD-10 codes (e.g., schizophrenia) that could receive and benefit from services. Future work can incorporate perspectives of other patients with mental health needs, informing a more transdiagnostic approach to mental health treatment.³⁷ Relatedly, we spoke only to English or Spanish-speaking adults to maintain the study’s feasibility, which likely further narrowed the perspectives offered. Immigrants and refugees often have greater unmet mental health needs,³⁸ and although respondents from Central and South America were represented, other regions were not. As FQHCs often provide services germane to migrant populations (e.g., immigration medical examinations), they can serve as a useful entry point for mental health support for this population.

Other limitations include the potential for social desirability (given the interviewer’s affiliation with the clinic) and response biases (respondents who participated likely are those with less neutral views). Although we intended to listen primarily to patient voices, future work could incorporate staff and provider perspectives to elaborate on findings herein.

Conclusion

In light of expanding need for behavioral health supports for low-income and BIPOC communities, FQHCs are well positioned to offer timely, evidence-based therapies for their patient populations. Drawing on an ethnically diverse sample, this study clarifies barriers and facilitators influencing the uptake of mental health services for a common mood disorder. Although not intended to be generalizable, these insights may reflect broader challenges and opportunities that community-based organizations can consider.

Data Availability Statement

The data from this study are not publicly available but may be available upon reasonable request to the corresponding author.