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

Abstract

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.[5]Figure 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.[10]Figure 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 chro