By Katheryn Houghton for KFF Health News.
Broadcast version by Mark Moran for Big Sky Connection reporting for the KFF Health News-Public News Service Collaboration

States are redefining when medical professionals can get mental health treatment without risking notifying the boards that regulate their licenses.

Too often, health care workers wait to seek counseling or addiction treatment, causing their work and patient care to suffer, said Jean Branscum, CEO of the Montana Medical Association, an industry group representing doctors.

"They've invested so much time in their career," Branscum said. "To have anything jeopardize that is a big worry on their mind."

Montana, like other states, has a recovery program for health professionals who have a substance use disorder or mental illness. However, medical associations say such programs often come with invasive monitoring, even for voluntary care. And gray areas about when a mental illness should become public breeds fear that seeking care jeopardizes a medical career.

Montana is among the states looking to boost confidential care for health professionals as long as they're not deemed a danger to themselves or patients. In recent years, at least a dozen states have considered or created confidential wellness programs to offer clinicians help early on for career burnout or mental health issues. States have also reworked medical licensing questions to avoid scrutiny for providers who need mental health treatment. The changes are modeled after Virginia legislation from 2020.

During a legislative committee meeting last month, advocates for Montana medical professionals asked state lawmakers to follow Virginia's lead. They say the goal is twofold: to get clinicians treatment before patients are at risk and to curtail the workforce burnout that's partly fueled by untreated stress.

Montana's existing medical monitoring program, the Montana Recovery Program, is run by the global company Maximus. Montana's professional advocates had backed another nonprofit to run Montana's program, which didn't win the state contract.

The Montana Recovery Program declined a request for an interview, instead referring KFF Health News to the Montana Department of Labor & Industry, which oversees the state's medical licensing boards. Department staffers didn't comment by deadline.

In a Medscape survey released this year, 20% of physicians said they felt depressed, with job burnout as a leading factor. The majority said confiding in other doctors wasn't practical. Some said they might not tell anyone about their depression out of fear people would doubt their abilities, or that their employer or medical board could find out.

Health professionals are leaving their jobs. They're retiring early, reducing work hours, or switching careers. That further dwindles patients' care options when there already aren't enough providers to go around. The federal government estimates 74 million people live in an area without enough primary care services due to a workforce shortage.

Aiming to ensure patient safety, state medical boards can suspend or revoke clinicians' rights to practice medicine if substance use or psychological disorders impair their work. Those cases are rare. One study found roughly 4,400 actions against the licenses of U.S. physicians for either substance use or psychological impairment from 2004 to 2020.

Nonetheless, workforce advocates say disclosure requirements cause some health professionals to dodge questions about mental health histories on licensing and insurance forms or forgo care altogether. They're worried divulging any weakness will signal they shouldn't practice medicine.

The mental health questions health workers are asked vary by state and profession. For example, nurses in Montana renewing their license are asked if they have any psychological condition or substance use that limited their ability to practice "with reasonable skill and safety" in the previous six months. Along with being asked about substance use on the job, doctors are required to say whether they've experienced a mental condition that "might adversely affect any aspect of your ability to perform."

"When I see that question on my renewal, do I have to report that I was depressed because I was going through a really tough divorce?" Branscum cited as an example of workers' uncertainty. "You know, my life is turned upside down now. Am I obligated to report that?"

A "yes" wouldn't immediately result in licensing problems. Those who do report mental health troubles would be flagged by state workers as a potential concern. They could end up before the board's same screening panel that recommends whether to revoke a license, or be referred to long-term monitoring with regular screening.

Additionally, health professionals are required to report when other clinicians show unprofessionalism or have potential issues that affect performance. Branscum said medical professionals worry that what they say in a counseling session could be flagged for licensing boards, or that a co-worker may make a report if they seem depressed at work.

Bob Sise, a Montana addiction psychiatrist and co-founder of the nonprofit 406 Recovery, told state lawmakers that job stressors are playing into workers' mental health challenges, such as long shifts and heavy patient loads. And with the rising cost of health care, physicians feel they're sacrificing their commitment to healing as they routinely substitute optimal treatment for lesser care that patients can afford.

Sise said his practice now has roughly 20 health professionals as patients.

"They were able to access care before it was too late," Sise said. "But they're the exception."

In Virginia, doctors, nurses, physician assistants, pharmacists, and students can join the state's SafeHaven program. Melina Davis, CEO of the Medical Society of Virginia, said the service offers counseling and peer coaching with staffers available to answer a call 24/7.

"If you only have a moment at 2 a.m., or that's when you had the chance to first process the death of a patient, then you can talk to somebody," Davis said.

Those in the program are assured that those conversations are privileged and can't be used in lawsuits. This year, the state is considering adding medical diagnoses under the program's confidential protections.

States that have followed suit have slight variations, but most create a "safe haven" with two types of wellness and reporting systems. Those who seek out care before they're impaired at work have broad privacy protections. The other defines a disciplinary track and monitoring system for those who pose a risk to themselves or others. Indiana and South Dakota followed Virginia's lead in 2021.

States are also narrowing the time frame that licensing boards can ask about mental illness history. The American Medical Association has encouraged states to require health care workers to disclose current physical or mental health conditions, not past diagnoses.

Last year, Georgia updated its license renewal form to ask doctors if any current condition "for which you are not being appropriately treated" affects their ability to practice medicine. That update replaces a request for seven years of mental health history.

Even outside the "safe haven" framework, some states are grappling with how to grant doctors privacy while guaranteeing patient safety.

The Medical Board of California is creating a program to treat and monitor doctors with alcohol and drug illnesses. But patients' advocates have argued too much privacy, even for voluntary treatment, could risk consumers' well-being. They told the state medical board that patients have a right to know if their doctor has an addiction.

Davis said states should debate how to balance physicians' privacy and patients' safety.

"We in medical professions are supposed to be saving lives," she said. "Where's the line where that starts to fall off, where their personal situation could affect that? And how does the system know?"

According to the Montana Recovery Program website, it's not a program of discipline but instead one "of support, monitoring, and accountability." Participants may self-refer to the program or be referred by their licensing board.

Branscum, with the Montana Medical Association, said the state's monitoring program is needed for cases in which an illness impairs a clinician's work. But she wants that form of treatment to become the exception.

Vicky Byrd, CEO of the Montana Nurses Association, said nurses don't tend to join the program until they're forced to in order to keep their license. That leaves many nurses struggling in silence until untreated illness shows up in their work, she said.

"Let's get them taken care of before it has to go on their license," Byrd said.

Because after that point, she said, it's hard to recover.


Katheryn Houghton wrote this story for KFF Health News.


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Wyoming ranked highest in the nation for suicide rates four consecutive years through 2021, according to the Centers for Disease Control and Prevention, and the state is funding more crisis response.

About 90% of calls to Wyoming's 988 crisis response line get an in-state answer, according to a new report. Calls used to be routed elsewhere, but the state has been working to localize responses.

Two Wyoming call centers opened in 2020 to offer 24/7 support and now average about 500 in-state calls per month, according to the Wyoming Department of Health.

Kim Deti, public information officer for the department, said the state is currently working to house the helpline's text and online chat options in-state too, and a local connection is important.

"We believe that people within Wyoming, whether they're calling, texting or chatting, they may feel more able to connect and relate to someone from their area," Deti explained.

A 2023 state law created a trust fund for the program but failed to add money to pay for it. This year, a proposed $40 million allocation was reduced to $10 million in the final state budget. Federal funds are also available through July 2025.

If you or someone you know is in crisis, help is available by calling or texting 988.

The nonprofit Inseparable published a report this month to improve crisis response systems. It encourages states to pursue policies to develop system infrastructure, accountability, workforce capacity and sustainable funding.

Angela Kimball, chief advocacy officer for the mental health advocacy organization Inseparable, said in terms of payment, response to mental health emergencies should look like the response to other emergencies.

"Police come. They don't ask whether or not there's an insurance card or a payer first. And the same is true for mental health, substance use, and suicidal crises," Kimball urged. "We want there to be a response regardless."

Kimball argued there should be funds for mental health crises beyond Medicaid.

Florida is getting attention for its efforts to create a comprehensive crisis response system for mental health needs.

A new report by the mental health advocacy group Inseparable calls for policies to expand 988 call center capacity, increase the availability of mobile response units, create more crisis stabilization centers and establish stable funding mechanisms to sustain the services.

Melanie Brown-Woofter, president of the Florida Behavioral Health Association, said the Sunshine State is doing all that and more to provide care for anyone in crisis, including adding more clinics.

"And now the certified community behavioral health clinics, we are really building an entire system that allows an individual in crisis to seek care and be linked to the right level of care at the right time," Brown-Woofter explained. "And to have those resources available that they need."

She pointed out with Florida operating mobile response teams for over 30 years, it is well ahead of other states. She notes the increased state funding to expand services and to establish central receiving facilities, which are not yet available in every state.

The facilities provide what she described as a full continuum of care, from crisis intervention to residential treatment, detox services and child care, all in one location.

Angela Kimball, chief advocacy officer for Inseparable, said it features solutions designed to ensure everyone in a mental health crisis receives the right services at the right time and provides a detailed roadmap for lawmakers.

"Our real goal here is to help create a very visual, easy to understand tool that lets them understand how they can be that champion," Kimball emphasized. "That helps ensure that no one's worst day keeps them from living their best life."

Another objective for Kimball is to spark conversations about what is achievable. For instance, the report showcased Oklahoma's RideCare program, which offers non-law enforcement transportation to urgent recovery centers. Oklahoma also distributed nearly 30,000 iPads equipped with crisis de-escalation tools to first responders and others.

Georgia provides "Peer2Peer Warm Lines" offering 24-hour support from trained specialists to people facing challenges who may not require emergency response.

June is Men's Mental Health Month and advocates in Ohio and elsewhere are working to eliminate the shame or judgment guys often face when they struggle with mental illness.

Studies show the prevalence of mental health problems is growing among children and adults but men are less likely to seek care.

Javon Howard, manager of engaging men initiatives for the Ohio Alliance to End Sexual Violence, said men need to understand it is OK to have experienced trauma and they need to find ways to better connect to their emotions.

"It's important to bring awareness to this month and bring awareness to men's mental health, because we want to encourage men to seek help," Howard explained. "We want to encourage men to feel like they are able to identify for themselves when they do need help, and to understand how to use the tools that are around them."

Studies show women have a significantly higher frequency of depression and anxiety in adulthood, while men have a higher prevalence of substance use disorders and anti-social behaviors. However, four times as many men die by suicide than women and both categories are on the increase, according to the Centers for Disease Control and Prevention.

Howard noted men often believe they will be perceived as weak if they seek mental health care. He observed the culture often tells men to "just get over it," to "man up" or "quit being a sissy." He added the fact large parts of Ohio are rural rather than urban brings a special set of problems for men seeking help.

"With Ohio being a rural state, the reality of folks having access to services can be difficult," Howard emphasized. "If you live in a community where everyone knows each other, it's harder to keep things closer to what's going on with you."

Howard added Men's Mental Health Month highlights the growing number of men across the country dealing with stress, anxiety and depression. His organization hopes to change attitudes about men seeking help to overcome their problems.