TWO DISTURBING TREND lines are currently crossing in the area of mental health care. One line, tracking demand for such care, is rapidly rising. In the U.S., nearly 1 in 5 people has some sort of mental health condition, according to the Journal of the American Medical Association. The disease burden – the impact of a health problem as measured by financial cost, death rates, disability and other measures – of mental health and substance use disorders was higher than for any other condition in 2015, JAMA reported.
The other trend line, measuring the number of mental health care providers in practice, is barely holding steady. A 2016 report released by the Health Resources and Services Administration projected the supply of workers in selected behavioral health professions to be approximately 250,000 workers short of the projected demand in 2025. And the Review of Physician and Advanced Practitioner Recruiting Incentives, a 2017 report from the physician search firm Merritt Hawkins, states that, "The shortage of psychiatrists is an escalating crisis … of more severity than shortages faced in virtually any other specialty."
There are many reasons for the supply of mental health professionals falling short. "Historically, the demand [for treatment] has not been as strong due to higher levels of stigma and lower rates of treatment being sought," says Dr. Jerry Halverson, chief medical officer for Rogers Behavioral Health in Oconomowoc, Wisconsin. With demand now growing as the social stigma lessens, "The supply has not caught up yet," he says. Also, there is a perception that inadequate pay is discouraging some students from choosing mental health fields as a specialty, he adds.
The problem is most acute in rural areas, he says, because most mental health professionals, like professionals in other fields, tend to cluster in urban areas. Also, like other providers, mental health professionals are spending more and more time on paperwork for insurance companies. "That can interfere with a psychiatrist's ability to have the time to sit with patients," Halverson says. And then there's the fact that more than 60 percent of practicing psychiatrists are over the age of 55 and nearing retirement – one of the highest proportions among all specialties, according to an American Academy of Medical Colleges 2015 report.
All of these challenges are daunting – but not insurmountable. Many mental health care organizations are hard at work addressing these issues in order to create more providers and offer more and better access to care to address the ever-growing mental and behavioral health needs in the U.S.
Troubling Numbers But Hopeful Answers
The numbers are indeed troubling:
- More than half of U.S. counties have zero psychiatrists, according to a 2016 Health Affairs report.
- About 111 million people live in "mental health professional shortage" areas, says the U.S. Department of Health and Human Services.
- Two-thirds of primary care physicians report difficulty referring patients for mental health care, twice the number reported for any other specialty, according to the journal Health Affairs.
- The number of patients going to emergency departments for psychiatric services over a recent three-year period increased 42 percent, the National Council for Behavioral Health reports.
But the responses are hopeful. There is increased effort in recruitment for and training capacity in many mental health disciplines, Halverson says. "For example, in Wisconsin, post medical school specialty psychiatric training positions have been added to existing programs at the University of Wisconsin and the Medical College of Wisconsin. The Medical College has located some of these training slots in more rural areas to help meet the demand in those areas." This effort is paying dividends, he says. "This year was a record-breaking year at the Medical College of Wisconsin for medical students to choose psychiatry as a specialty, and there were actually students who wanted to go into psychiatry but were unable to find a place to do their training and may have to begin their training in primary care." Those results are reflected across the country, as the number of new psychiatry residents grew 5.3 percent, from 2010 to 2015, according to the AAMC.
Along with minting more providers, the field is looking to new models of care to improve access to the providers that already exist. "Other innovative ways of extending the mental health workforce that are being successfully utilized across the nation include telepsychiatry and integrated care," Halverson says. "Both are ways to bring the psychiatric resource to where the patient is, rather than doing what has always been done – bringing the patient to the mental health professional."
Telepsychiatry uses the power of the internet to conduct videoconferencing for patient evaluation, treatment and medication management. Integrated care means enhancing coordination between mental health care providers and primary care or family practitioners. Often that includes telemedicine technology, to allow the two physicians to consult at a distance. It may also involve embedding mental health providers in primary care practices, where they consult on or oversee cases and see only the most challenging patients. A 2012 review of this collaborative care model, published in Cochrane Review, found "significantly greater improvement" in outcomes for adults with depression and anxiety. These results are so promising that the Centers for Medicare& Medicaid Services has ponied up $2.9 million to train 3,500 psychiatrists in this model.
Challenges and Opportunities
Next week, a special supplement to the American Journal of Preventive Medicine will be published to address this important issue. Titled The Behavioral Health Workforce: Planning, Practice, and Preparation and sponsored by the Substance Abuse and Mental Health Services Administration and the HRSA, both under the aegis of the Department of Health and Human Services, the supplement comprises a set of articles that propose research-driven strategies and best practices to address the needs of current and future behavioral health care providers. Among them:
- Creating the Interdepartmental Serious Mental Illness Coordinating Committee, which in its first year identified 45 recommendations in five focus areas to improve access to, quality of and affordability of care. Among these are promoting telemedicine, early screening and intervention and boosting reimbursement rates to meet those of other health care services.
- Funding the Behavioral Health Workforce Education and Training Program, which has supported the training of more than 9,000 new behavioral health care professionals and more than 2,000 behavioral healthcare paraprofessionals.
- Funding Certified Community Behavioral Health Clinics in 24 states (including many highly rural states). In fiscal year 2018, $100 million in new funding is being awarded through a new expansion grant program to community clinics.
- Accepting applications to develop or expand what are known as Assertive Community Treatment programs, which are expected to improve behavioral health outcomes for individuals by reducing rates of hospitalization, mortality, substance use, homelessness and involvement with the criminal justice system.
- Supporting a Community Mental Health Services Block Grant program that offers money and technical assistance to provide comprehensive, community-based mental health services to adults with serious mental illnesses and to children with serious emotional disturbances and to monitor progress in implementing a comprehensive, community-based mental health system.