By Louise Radnovsky
February 16, 2015
Millions of Americans with mental illness are hearing a loud and clear message: Get help. There’s still one question: Who is going to treat them?
The shortage of mental-health providers in the U.S. has long been considered a significant problem. But it is becoming more acute as people are encouraged to seek treatment, or find they are able to afford it for the first time as a result of new federal requirements that guarantee mental-health coverage in insurance plans.
That’s prompting a sea change in attitudes among mental-health advocates, who are starting to look at solutions that are broader than just training more psychiatrists.
Some 96.5 million Americans were living in areas with shortages of mental-health providers as of September 2014, according to an assessment by the Health Resources and Services Administration, a unit of the Department of Health and Human Services. That number is up from around 91 million in 2012.
Explanations for the shortage of psychiatrists include the long pipeline for training them, as well as low pay and high turnover for some positions. The attempted solutions have often mirrored proposals for addressing the national shortage of primary-care physicians—and have had few successes in making a dent in the problem.
There has been no increase in federally funded residency slots to train physicians, despite provider groups pushing hard for this for more than 15 years. Federal payments to incentivize people to work in areas that find it particularly hard to attract physicians, meanwhile, have succeeded in alleviating some of the most acute shortages, but have done little to address the broad shortage that persists nationwide.
The result is a growing acceptance that psychiatrists aren’t the only acceptable mental-health providers, even from groups that have long resisted this.
“If you’re starting to feel unwell, you don’t go straightaway to an oncologist or a surgeon,” says Debbie Plotnick, senior director of state policy for Mental Health America, an advocacy group. “We need to educate the public there are more than just psychiatrists.”
Even the American Psychiatric Association has warmed to its physician members’ working more closely with nurse practitioners and physician assistants, after a long history of protectiveness over its members’ powers. The organization last year released a commissioned report seen as a major shift by many, including Ms. Plotnick. The report called for team-based care for people with mental illness and substance-abuse disorders.
“The roles are defined. Everyone is treating to outcome and remission,” says Sam Muszynski, the psychiatric association’s director of health-care systems and financing. “There are just treatment protocols that need to be followed.” He notes that under the team model, the physicians remain in charge, supervising other medically trained providers.
Some local health-care systems have gone further. Philadelphia’s behavioral-health-services department has been trying to use as many kinds of mental-health providers as possible, including many who aren't medically educated and who are themselves users of mental-health services. For example, the city has recruited, trained and paid 643 “peer specialists” to help other people with mental illness in treatment programs, in some cases doing it with dollars from Medicaid, the federal-state insurance program for low-income Americans.
At the same time, the city now offers higher payments to psychiatrists to encourage them to see patients with Medicaid, which typically keeps its costs down by offering lower reimbursements, says Arthur C. Evans Jr., the department’s director since 2004.
“We have seen decreases in crisis visits, less inpatient recidivism, greater clinical stability and the per-person cost go down, while increasing the number of people being served in the system,” Dr. Evans says of the city’s approach.
California community-health centers are also gaining acclaim for their efforts to merge primary-care and behavioral-health services under one roof, which often ensures that many aspects of mental health can be addressed by providers other than psychiatrists.
Help From Technology
Health-care officials also hope that technology can provide assistance in relieving the shortage.
Robert Bosch Healthcare Systems Inc. says it has developed a device that providers can use to monitor patients with bipolar disorder and major depression, to make sure they are managing their illness through medication and behavioral therapy.
The device, based on technology used for people with heart disease and diabetes, uses branching logic to ask patients a series of questions about their symptoms in a five-minute daily session. It then offers guidance on what they should be doing in response. The answers are reviewed by a care manager, usually hired by an insurer, who flags any need for further intervention.
A Journal of Mental Health study published last year of 38 users of such a device found an 82% decrease in hospital admissions and 75% decrease in emergency-room visits, with participants reporting improvements in quality of life as well.