Growing shortage of psychiatrists and enormous demand for mental health services

In 2019, 1 in 5 people in the United States had a mental illness, and a total of 51.5 million people had a mental illness. Then the new coronavirus infection occurred.

Fear of contracting a deadly virus, loss of loved ones, painful social isolation, economic setbacks and other powerful stressors have eroded the well-being of communities across the country. At the height of the pandemic, 40% of his adults reported symptoms of anxiety and depression, compared with 11% before COVID-19. Over time, this percentage has dropped to 33% in June 2022, but is still higher than pre-pandemic levels.

But the United States does not have enough mental health professionals to treat everyone who is suffering. More than 150 million people already live in federally designated mental health professional shortage areas. Within a few years, experts say, there will be a shortage of 14,280 to 31,109 psychiatrists in the country, as well as a surplus of psychologists, social workers and others.

“There is a chronic shortage of psychiatrists and there will continue to be a shortage,” said Saul Levin, M.D., CEO and medical director of the American Psychiatric Association. “People are not getting care. It affects their lives, work, socializing and even their ability to get out of bed.”

Moreover, the gap between needs and access is widening among some people, including those in rural areas. In fact, more than half of US counties don’t have a single psychiatrist. Howard Liu, M.B.A., a psychiatrist at the University of Nebraska Medical Center (UNMC) in Omaha, says that in Nebraska, “even very sick people have to wait months to get an appointment.” There are things I can’t do,” he says.

Several factors will accelerate the shortage. “The U.S. population is growing, and mental health needs are increasing, especially because of the pandemic, but we don’t have enough training slots to train people,” said Anna Ratzliff, M.D., Ph.D., director of the University of Washington Psychiatric Training Program. says. (UW) Located in Seattle. With more than 60% of psychiatrists over the age of 55, there is also an outflow of retirement benefits.

“People are not getting care. It affects their lives, work, socializing and even their ability to get out of bed.”

Saul Levin, MD
American Psychiatric Association

In response to dramatic needs, leaders in this field are working hard to find effective solutions. Some use telemedicine to see patients wherever they are. Some focus on recruiting and training new psychiatrists.

In addition, some aim to educate and support primary care providers (PCPs), the frontline physicians who treat most mental health patients. Experts say such a collaborative, interprofessional approach is critical to closing the gap in psychiatry.

Daniel Gui, M.D., Director of the UNMC Psychiatric Training Institute, says the need for collaboration is ultimately down to the numbers. “Even if all medical students chose psychiatry, the country would sadly still be very understaffed,” he says.

produce more psychiatrists

Training more psychiatric residents alone will not fully meet the growing mental health needs, but remains essential, experts say.

“It’s important to create new housing slots. Ultimately, that’s the only way to get more psychiatrists,” says University of Wisconsin Medical School, co-author of a 2021 study on the issue. Art Walasek, M.D., a psychiatrist at the Graduate School of Public Health in Madison.

However, providing training is expensive and government funding is limited. In 2020, legislation increased Medicare-supported housing quotas for the first time in decades. The move added 200 seats each year for five years and spread across the country and all medical specialties. In addition, the proposed Resident Doctor Shortage Reduction Act, if enacted, would add 2,000 more each year for seven years. However, the costs of new psychiatric slots are almost always borne by individual institutions.

In some cases, expanding residency means increasing slots in existing programs. In some cases, it may be necessary to write an entirely new program.

Building a new program is no easy task. “There are many certification rules and regulations that must be learned. [attending] Physicians spend time on training education and administrative duties. It’s like managing a small workforce,” Gui says.

Having recently added 16 more psychiatric slots, UW’s expansion includes building a new behavioral health education facility with larger rooms to accommodate more trainees. Slots and buildings are thanks to state subsidies, another common source of housing funding.

That’s where the question arises. If you build it, will students come?

In the past, recruiting psychiatrist applicants was somewhat difficult, but things are changing. In fact, the number of psychiatric residents has increased by 21% in recent years, and by 2022 there were nearly double the number of applicants.

Giff points to a generational shift. “People now want careers that offer a better work-life balance. They also want to work in fields that give them a more holistic view of patients. I think more deeply about issues such as human capacity to function and their place in society,” he says.

“It’s important to create new housing slots. Ultimately, that’s the only way to get more psychiatrists.”

Dr. Art Walashek
University of Wisconsin School of Medicine School of Public Health

Of course, any training program needs to attract and retain teachers. That may be difficult, Walasek said, because academia can be more bureaucratic and less profitable than private practices. “It’s important to find ways to deal with burnout and increase flexibility. Otherwise, faculty may cut their hours or retire entirely.”

If that happens, the field will face a problem, says Walashek. “They are what we need to train future psychiatrists and to get medical students interested in careers in this field.”

digital doctor

Like other medical fields, the pandemic has brought mental health care online. However, while telemedicine has returned to a small fraction of overall care at 5%, the proportion of mental health services delivered through telemedicine remains high at 40%.

This is notable because virtual care can also help expand the workforce, experts say.

“Telemedicine allows us to work longer hours by not being restricted to brick-and-mortar clinics that are open from 8 to 5,” says Matt, assistant professor of psychiatry at the University of Colorado Anschutz Medical Campus. Dr. Mishkind says. in Aurora. Experts say it also helps reduce burnout by reducing commute times and allowing health care providers to serve a more diverse set of patients they otherwise couldn’t treat.

Expanding services to underserved communities is one of the biggest benefits of telemedicine, says a psychiatrist at the University of California, San Diego Health School who treats many patients remotely in Southern California. says Dr. Jessica Tuckerberry.

Some of Tuckaberry’s patients live in areas with no access to psychiatrists and have traveled to Mexico for treatment. For those, telemedicine can be life-changing, she says.

“We had one patient whose anxiety caused him to act out. He would end up in an inpatient facility far away from his family. We were able to make adjustments and keep him at home.”

Such treatments are feasible thanks to the flexibility of recent telemedicine regulations. For example, Medicare lifted some telemedicine payment restrictions during the pandemic, and some of the changes were made permanent. But experts continue to monitor other obstacles, such as states ending pandemic-related waivers that allow out-of-state doctors to provide telemedicine.

Meanwhile, other professionals are exploring additional digital means to expand access to care.

One option is an online, self-paced cognitive-behavioral therapy (CBT) module, Mishkind says, an approach backed by a growing body of research. This type of tool not only increases access for patients, it also frees up time slots for healthcare providers. “Patients may have CBT training and then meet with their provider for 20 minutes instead of 50 minutes. Mental health apps, which could help expand access, are also proliferating, but their quality varies, says Mishkind.

At Emory Healthcare in Atlanta, Brandon Kitay, M.D., wants to balance access and quality by bringing mental health apps in-house. The digital platform, which Emory has implemented with the help of an outside technology company, collects patient data to monitor needs, deliver voluntary treatment, and make it easier for healthcare providers to access, among other services. to provide comprehensive online support.

Kitay said Emory’s app will be ready for deployment within a year, with a pilot project for two years of research. “We’ll have to see if this works, but if we’re going to extend care, this is the kind of thing we have to try.”

collaboration that matters

Experts say that if we want to help as many patients as possible, we need to reach out to primary care offices, where patients tend to congregate. In fact, almost 60% of patients receiving mental health treatment are from her PCP.

Among the various options for delivering psychiatric expertise through PCP offices, the evidence-based collaborative care model is often the approach of choice.

Here’s how it works: PCP tests patients for anxiety and depression. After obtaining a positive result, the doctor takes the patient down a hallway to a behavioral care manager (BCM), usually a psychologist or social worker, who examines the patient’s symptoms further. I can. Care managers usually provide care, monitor patients, and actively reach out to patients who are not improving. The PCP team meets regularly (usually once a week) with a partner psychiatrist for information such as medication management.

“In my psychiatric clinic, I can see one patient an hour, but with co-treatment, I can help treat 10 to 12 patients at the same time,” says Rachel Weir, the university’s director of mental health integration. says the doctor of medicine. of Utah Health in Salt Lake City. “This is a very dramatic expansion of access.”

For University of California’s Ratzliffe, one of the benefits of the model is that patients get the care they need more quickly. She recalls a doctor who noticed signs of depression in a patient during a checkup. The patient met with the BCM on the same day and was immediately placed on medication and treatment under psychiatric supervision. “It is unlikely that he would have been treated elsewhere,” Ratzliff said. “Patient’s mother’s credit [Collaborative Care] She saved her son’s life. ”

“We can see one patient an hour, but with Collaborative Care, we can help care for 10 to 12 patients at the same time.

Rachel Weir, MD
Utah Health College in Salt Lake City

Some psychiatrists pursue other interprofessional options because establishing co-treatment can require substantial infrastructure and training. These include eConsults, where experts can share their expertise in a simple remote exchange.

At Emory, Kitei explains: “We established a mechanism for answering formal questions rather than hallway conversations between random doctors. becomes part of the patient’s medical record, so other providers can see it.”

At Utah Health College, leaders are preparing to launch an electronic medical record feature. This feature automatically offers treatment options to healthcare providers when a patient tests positive for mental health concerns, and is “just a matter of ‘you figure out what to do’.” not,” says Weir. .

Support for PCPs also comes in the form of Project ECHO sessions offered by various teaching hospitals across the country. At the event, a psychiatrist will speak on topics such as her LGBTQ+ mental health, and remote attendees will not only learn from the lectures, but also from discussions about the cases they see in their practice. And there is also a phone line where PCPs can get advice from psychiatric professionals. For example, two years ago, UW established a system that he would run 24/7.

In all this effort, educators also focus on training prospective psychiatrists to collaborate with their PCP colleagues. In fact, more than half of psychiatric programs report teaching residents how to work with clinicians from other disciplines.

“We tell residents that as a psychiatrist, your role is no longer just about providing individual patient care,” says Ratzliffe. “An important part of your role is teaching and being a resource for your colleagues.”

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