Barbee operates Renaissance Wellness Services, which primarily provides mental health services in public schools.
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"I remember warning my staff at the beginning of the school year in August that we were going to see an increase in services, but I don't think any of us were prepared for the number of referrals or the demand that actually showed up," Barbee said.
Her business went from getting 10 referrals from students a week to 10 a day.
"We were kind of sitting there like, 'Oh my gosh, what do we do? This one school system has already referred 10 kids and it's not even lunchtime on Monday morning,'" Barbee said.
The need she saw echoed across the nation as students returned to the classroom in fall 2021.
Emergency room visits for mental health among children increased early in the pandemic. The Centers for Disease Control and Prevention (CDC) reported mental-health related visits for children from 5-11 years old increased by 24% and by 31% for kids 12-17 years old.
It's not just children
Mental Health America's 2022 'State of Mental Health in America' report found nearly one in five adults experienced a mental illness and the percentage with unmet need for treatment has increased year over year for the past decade.
As need rises across the nation, many North Carolina providers and communities struggle to keep up.
An ABC Data Team analysis found in Chatham County there are around 2,400 patients for every provider. Compared to nearby counties, providers in Chatham County are faced with three times more patients than in Wake County and eight times more patients than in Orange County.
In other rural areas, such as Sampson County and Duplin County, the rate of patients to providers is more than double Chatham's rate. The ABC Data Team's analysis found Currituck County had the highest ratio with 6,800 patients for every one provider.
This is a trend across the country.
The ABC Data Team's analysis uncovered that 570 counties have no mental health care providers; 79% of those counties are considered rural. In North Carolina, the analysis found only Graham and Gates County had no providers.
An estimated 27 million Americans are going untreated for mental illness, according to a 2022 report from Mental Health America. One in four adults who suffers from a mental illness reported an unmet treatment need this year; a percentage that grows every year, according to Mental Health America.
Barbee, a Chatham County native, is aware of these gaps across the state and said it is why she expanded her practice to Siler City and Pittsboro.
"It's just continuing to put the word out that these individuals these people are just as important as people that live in urban areas," Barbee said. "I want people that live in Chatham County, in a rural area like Chatham where I am from originally, to be able to receive not just mental health services, but quality mental health services."
Despite her expansion to Siler City, she said her practice continues to get referrals daily and has a waitlist.
A decrease in staffing
Another part of the problem is staffing. Even if providers can open a physical location in an underserved county, hiring enough staff to adequately serve the community has become an increasing challenge.
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"Before COVID, pre-pandemic, it was already difficult to staff a rural area because it's a rural area and that's just kind of the nature of it," Barbee explained. "But since Covid, it's amazing, but it's really across the board in the rural areas in Chatham, and also in the more populated area. We're definitely struggling to find qualified staff like never before."
Barbee said she has about six open positions.
Billy West, the CEO and President of Daymark Recovery Services said his staff has shrunk by 31%, or 350 employees.
"That makes it very difficult because we're not seeing fewer patients and we are seeing in some cases, sicker patients," West said.
Daymark Recovery Services offers inpatient and outpatient services related to the treatment of mental illnesses, substance use disorders, and developmental disabilities.
Through the years, the need for these services has caused the group to expand from five counties to 28.
"We used to be 'it' in a lot of the rural counties. Right now there is a choice in some of the counties but we do the lion's share of the psychiatry and in most of those counties, particularly rural counties, we do almost all the walk-in crisis in those counties," West said.
The decrease in staff has meant they've had to cut back on how many people can utilize their in-patient services.
"We end up having to restrict admissions. And that means people either end up in the emergency room if they were choosing us first or they're staying in the emergency room, because they're ready to leave, but they can't go home and we're unable to take them in our inpatient units. So it really creates a backlog," West said.
Another impact on a shrinking mental health professional workforce is accessing.
A March 2022 report from the Addictive Professionals of North Carolina surveyed the state's behavioral health workforce and found an increase in barriers to accessing services including cost and staff shortages.
"Telehealth was a godsend to us early on in the pandemic. But even telehealth can't compensate for just physically not having bodies, particularly around our inpatient crisis services and our direct care staff," West said.
The March 2022 report from the Addictive Professionals of North Carolina survey found a majority of behavioral health care workers make less than $40,000. Around 46% of the frontline workers surveyed ranked 'raising salaries' as one of the top retention efforts.
West said while pay does need to increase across the board, it's not the only factor driving people from the profession. Burnout is also high with 67% of workers reporting at least one symptom in the last few months, according to the Addictive Professional of NC survey.
Both Barbee and West said colleges and universities are key players in working towards a solution.
"It starts making sure the university systems understand and the community college systems understand the workforce needs, starting to promote those programs," West said.
Insurance a factor
"Access is not just is there enough people, right? It's are they distributed where they need to be? Is it affordable? Is it acceptable?" said Brianna Lombardi, the deputy director of UNC's Carolina Health Workforce Research Center.
Lombardi pointed to another key barrier for people; cost.
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"The thing about rural settings is thinking about what insurance that person has or self-pay, and that's really the limiting factor right now in accessing care," Lombardi said.
She estimated only around half of the psychiatrists nationwide accept insurance.
Mental Health America estimated that 11% of Americans with a mental illness are uninsured.
"Expanding Medicaid as a way to get access to services is probably really important, particularly for folks who have high mental health needs," Lombardi said. "Having a way for them to have insurance would be helpful for them accessing care, and not just in one point of time, but the continuity of care that it would take to really address the mental health needs so that they're able to engage in the community how they would like."
The role of telehealth
Though the data shows gaps in physical providers, it doesn't account for the expansion in telehealth options.
During the pandemic, a growing number of online national mental health sites popped up that allowed people to connect to resources that weren't directly housed in their communities. Many providers located in more urban counties such as Wake County were also able to expand services virtually to rural areas.
"It really helps for folks with transportation access issues. It really helps with scheduling within their day. You know, it helps when they don't have to get childcare to come," Lombardi said.
Barbee said although those options have helped, they don't entirely break down barriers to access.
"I wouldn't say that it has been the answer. It's been helpful. Definitely. But it's not the answer until you have better internet access for individuals that live in more rural areas," she said.
While Lombardi agreed that further expansion of broadband is needed, she thinks the increase of virtual options has helped break down some stigmas associated with mental health.
"The genie is out of the bottle, you can't go backward, which I'm really thankful for because it theoretically increases access to care, particularly for folks who even maybe once in a while could make a 45-minute trip to see someone, week-to-week would not want to do that," she said.
Lombardi said in the future providers need to be better trained to deliver care that way and everyone needs to be thinking about how to make even that option affordable.
"There's not a magic pill we can take for this and say, 'We'll be better in seven days,' But there is progress. I'm hopeful we have to be hopeful. I see it. And so far, we're coping with it," West said.
The ABC Data Team used information from the Centers for Medicare and Medicaid Services' National Plan and Provider Enumeration System for its analysis.