The shortage of psychiatrists and other mental health providers: Causes, current state, and potential solutions

INTRODUCTION Psychiatry developed into a medical specialty area in the late 18th century in France.1 By the 19th century, the thought of psychiatry as a field of medicine began gaining momentum in other countries, and in 1944, the establishment of the American Psychiatric Association was essential in channeling energy into psychiatry's development here in the United States.2 Over the next couple of decades, an increasing number of graduating and established physicians began choosing psychiatry as their field of specialty. However, this initial influx was short lived and the trend had slowed down substantially.3 Over time, an unsustainable status quo emerged, with alarming statistics and predictions of acute mental health provider shortages issued by the Association of American Medical Colleges in 2016.3 This commentary will discuss the current state of affairs regarding the severe shortage of mental health professionals, including psychiatrists, psychologists, and mental health nurses.4 Potential solutions to this emerging crisis will be proposed. PSYCHIATRY: A SPECIALTY IN CRISIS There is a significant heterogeneity of practice patterns within psychiatry. This, in turn, contributes to unique challenges in terms of patient access to services. For example, approximately 5% of psychiatrists treat only inpatients, and about 15% of practitioners provide only child and adolescent services. In addition, there is a substantial proportion of practicing psychiatrists who are nearing the end of their careers Figure 1. Finally, a significant number of psychiatrists choose to reduce their professional commitment to part-time hours for variety of reasons.5Figure 1: Approximately 70% of practicing psychiatrists are >50 years of age, compared to 55% of the overall physician population in the US (Source: AMA Physician Master File, 2013)Decreasing number of psychiatry residencies, fewer graduates from remaining programs, combined with the above-mentioned professional trends within the specialty, all synergistically contribute to the worsening shortage of mental health practitioners.4 In addition, mental health professions have been experiencing low job satisfaction levels and burnout around the globe, further compounding the already challenging situation and potentially deterring new entrants into the specialty.6,7,8 As astutely pointed out by DeMello and Deshpande, “…threat of malpractice lawsuit, practices that admit Medicare patients and patients with considerable out-of-pocket medical expenses can have a negative impact on career satisfaction.”9 In addition, Prosser et al.8 point out that community mental health work may be more stressful than hospital work and that providers in the community face significant professional strain due to limited resources and relative lack of support. Although these are not new issues for psychiatrists or other primary care providers, the current crisis is approaching an unsustainable state of affairs. Why, some may ask, is the crisis more urgent today? THE CURRENT STATE OF AFFAIRS: APPROACHING CRITICALITY While the shortage of mental health providers is not a new phenomenon, the problem continues to grow and has become more apparent than ever Figure 2. The critical nature of the current situation is due to the fact that concurrent to the decline in the number of trained psychiatrists is the increase in demand for mental health services. For example, the demand for child and adolescent psychiatry services is expected to double between the years 2000 and 2020.10 It is not difficult to project that the already overextended resources available to behavioral services around the country would not be able to maintain the current and largely inadequate levels of coverage in the face of doubling demand. The same authors also emphasized that only about two-thirds of the resources needed would become available by the end of this decade, provided that current funding and recruitment levels are able to be maintained.10Figure 2: Key statistics representing the magnitude of mental health burden in the US. Given the projected increase in demand for mental health services, significant efforts must be undertaken to change the current status quo (source: http://www.cdclv.unlv.edu/healthnv/mentalhealth.html)With respect to general practice, nearly one in five counties (18%) in the US have reported an unmet need for nonprescribing providers (psychologists, social workers, advanced practitioners, therapists, and counselors).11 Moreover, nearly every county (96%) had an unmet need for prescribers (psychiatrists).11 Rural counties and those with low per capita income had higher levels of unmet need.11 Consequently, in addition to shortages in referral-based services, there is a high risk for various forms of trickle-down effect, including homelessness, increased burden on the criminal justice system, and overburdened existing community mental health services.12,13,14 The chronic lack of resources and continuing shortage of mental health providers is further compounded by maldistribution of resources that are available to the public. On the one hand, there is the shift of providing care from larger institutions to various community-based programs, which places increasing burden on the often underfunded public mental health services. On the other hand, certain urban areas with overabundance of psychiatrists contrast with more rural regions that have difficulty recruiting mental health professionals.15,16,17 A thorough understanding of both the nature and the reasons for such maldistribution is critical when planning for strategic resource allocation. Areas experiencing health-care shortages usually have higher levels of poverty, rural character, and/or larger proportion of minority residents.18 Thus, populations living in poverty-stricken areas, with greater overall mental health needs, experience limited access to mental health resources, which only exacerbates the already severe shortage.10 The burden of mental health specialist shortage affects other critically strained areas of the health-care system. Most prominently, the primary care sector has been forced to fill the void resulting from the lack of psychiatrists.19,20 It has been reported that approximately two-thirds of primary care physicians (PCPs) experience access-related difficulties when referring patients to mental health outpatient services – a figure twice that of other outpatient services requested by PCPs.19 Consequently, there is a growing number of PCPs providing screening procedures and psychiatric care to their patients.19 The reliance on PCPs to provide such specialized care is neither an optimal nor a sustainable solution to the mental health provider shortage. PROPOSED SOLUTIONS: FOCUS ON SUSTAINABILITY In an effort to come up with sustainable solutions for the ongoing critical shortage of mental health providers and services, a multipronged approach is required to adequately address all of the key areas of need Figure 3. This general strategy has been shown to be effective across various settings.21 A mental health crisis of the current magnitude is certainly multifactorial, with contributing elements including socioeconomic factors (e.g., lack of insurance coverage or community resources), provider-specific factors (e.g., high indebtedness combined with comparatively lower income levels), and the maldistribution of resources outlined earlier in this manuscript (e.g., ample supply of behavioral health specialists in large cities and near complete absence in rural areas).11,21,22 Many underserved areas experiencing mental health and primary care provider shortages are now utilizing incentives specifically designed to recruit new providers, such as loan repayment programs.22,23,24 Additional strategies used to attract new providers to this field include “…fellowship stipends, loan forgiveness programs, and clinical reimbursement; other strategies are to diversify the range of training opportunities available by establishing short-term training initiatives to meet specific demands.”8 This approach has proven somewhat successful; however, high turnover rates in some programs can pose a problem.Figure 3: Solution to the rapidly worsening shortage of mental health professionals must be multipronged and system-wide. Key elements of the effort are listed, with other potential components under active considerationAmong other notable programs, the National Health Service Corps (NHSC) sponsors an initiative that “…recruits fully trained professionals to provide culturally competent, interdisciplinary primary health and behavioral healthcare services to underserved population.”25 In return, the NHSC assists its participating provider members with student loan repayment.25 This and similar interprofessional education initiatives are designed to enhance collaborative approaches among public health and social work experts. The effort to integrate behavioral and physical health care helps address the increased demand for mental health services and improve patient outcomes by facilitating early diagnosis and intervention.25 Another potential component that may bring partial solution to the mental health shortage crisis is the utilization of pediatricians and PCPs to meet the increasing needs of younger patient groups. One such initiative was devised by the Resource for Advancing Children's Health (REACH) Institute.26 One program sponsored by REACH, the Child/Adolescent Training in Evidence-Based Psychotherapies combines interactive workshops and online curriculum.27 Another “mini-fellowship” course sponsored by REACH, the Patient-Centered Mental Health in Pediatric Primary Care curriculum provides education for nonpsychiatrist medical providers that features up-to-date training in the use of psychiatric medications for those 18 years of age and younger.28 This platform is intended to increase the comfort level of PCPs in evaluating and treating mental health issues in the pediatric population. The use of telepsychiatry has grown significantly as a response to the ongoing shortage of mental health-care providers, especially in the context of the underserved populations and regions outlined earlier in our discussion.29,30,31 As a technological approach, telepsychiatry can be very effective when treating patients with less severe mental health conditions.32,33 In this context, tele-psychiatry increases both accessibility and availability of behavioral health services while reducing the overall cost and the burden on practitioners who can the better focus on providing care for the more severely affected patients.34,35 In addition to fulfilling the critical role as an important access point to mental health care and a valuable consultative tool,35 telepsychiatry further supports “…the entire continuum of care, including patient assessment, psychoeducation, self-managed care, client-provider communication and direct treatment.”25 Many individuals suffering from behavioral health conditions do not seek professional psychiatric health services out of fear of the negative labeling. To help address these concerns, telepsychiatry offers greater anonymity and decreases the associated stigmas. Utilization of this general approach not only encourages the at-risk population to seek treatment but also provides a valuable resource for sustainable provision of much needed continuity of care.25 Another potential strategy to help alleviate the shortage of psychiatrists is the expansion of “prescriptive authority for advanced practice psychiatric nurses or psychologists.”11,36,37 While there continues to be some unease about this proposal, many localities have already extended this privilege to such personnel with notable success.36,37,38 The issue that arises with this approach falls within the need to adequately provide behavioral health training for advanced practice registered nurses and physician assistants.39,40 In the same light, it is important to ensure that psychologists are sufficiently educated in pharmacology to provide basic prescribing services.41,42,43 To provide sustainable, long-term solutions to the psychiatrist shortage, attention must focus on the early phases of medical education. The reasons why medical students choose not to pursue psychiatry as a career need to be explored in a systematic fashion. Many students and even physicians view psychiatry as a specialty that does not deal with medical problems the way that other specialties do.44,45,46,47 There are misconceptions about psychiatric patients among general public and medical students alike.47,48 The importance of creating and maintaining vibrant Psychiatry Departments in our teaching medical centers is critical to shaping the attitude of students and medical staff toward this noble specialty. In addition, more emphasis on routine management of common, uncomplicated medical illnesses during psychiatric training might be a powerful incentive for many physicians who like psychiatry but are concerned about losing their general medical skills. It may also be important to include in the medical student curriculum topics related to practice of psychiatry in the “real world,” instead of focusing exclusively on various clinical syndromes and treatment approaches. CONCLUSIONS The ongoing shortage of psychiatrists, combined with the increasing demand for mental health services, is evolving into a major public health crisis. There are several factors that contribute to this state of affairs, including maldistribution of resources, the relative lack of appeal of psychiatry as a medical career, and mismatch between psychiatrist income and levels of debt. Coordinated efforts are needed to address these key barriers to achieving sustainable growth and providing adequate mental health services to our communities.