One in five people in the United States will have a mental illness in 2019, totaling 51.5 million. Then COVID-19 hit.
Fear of contracting a deadly virus, the loss of loved ones, painful social isolation, economic recession, and other powerful stressors have eroded the well-being of communities across the country. During this period, 40% of adults reported symptoms of anxiety or depression, compared with 11% pre-COVID. Over time, this percentage has fallen to 33% in June 2022, but is still higher than pre-pandemic levels.
But there are few mental health professionals in the United States to treat everyone who suffers. Already, he lives in communities where more than 150 million people lack federally designated mental health professionals. According to experts, the number of psychiatrists in the country will drop from 14,280 for her to 31,109 for him within a few years, and there will be a surplus of psychologists, social workers and others.
“There is a chronic shortage of psychiatrists and it will continue to grow,” 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 need and access is wider among some people, including those in rural areas. In fact, more than half of the counties in the United States don’t have a single psychiatrist. Howard Liu, MD, MBA, psychiatrist at the University of Nebraska Medical Center (UNMC) in Omaha, says that in Nebraska, “sometimes you have to wait months to get an appointment. It’s the same,’ he said.
Several factors contribute to the shortage. “With a growing U.S. population, especially with more mental health needs due to the pandemic, there aren’t enough residency slots to train people,” said Anna Psychiatry, director of the Psychiatric Residency Program at the University of Washington. Ratsliff, MD, PhD, says. (UW) Seattle. There is also a retiree drain, as more than 60% of her psychiatrists are older than her 55.
“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 this dramatic need, leaders in the 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.
Others 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 essential to closing the gap in psychiatry.
The need for collaboration comes down to numbers, says UNMC Psychiatric Residency Director Daniel Gih, M.D., Ph.D. “Even if every medical student chose psychiatry, there would still be a significant shortage in this country, sadly,” he says.
find more psychiatrists
Providing psychiatric training to more residents alone will not fully address the growing mental health needs, but it is still essential, experts say.
“Creating new residency slots is very important. Ultimately, that’s the only way to get more psychiatrists,” said Madison, who co-authored a 2021 study on the issue. said Art Walaszek, M.D., Ph.D., psychiatrist at the University of Wisconsin School of Medicine and Public Health.
However, providing resident training is expensive and government funding is limited. In 2020, legislation increased Medicare-supported housing quotas for the first time in decades. The move has added 200 slots each year for five years and is spread across the country and all medical specialties. In addition, if the proposed Resident Doctor Shortage Reduction Act is enacted, it would add 2,000 more each year for seven years. However, in most cases, individual facilities will cover the cost of new psychiatric slots.
Expanding residencies may mean adding more spots to 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 a lot of accreditation rules and regulations to learn. [attending] Physician time for training education and administrative duties. It’s like managing a small workforce,” he says.
At UW, which recently added 16 psychiatric slots, expansion includes building a new behavioral health education facility with larger rooms to accommodate more trainees. Slots and buildings are thanks to state funds, another common source of residency funding.
The question arises here: Will students come if you build it?
It used to be somewhat difficult to attract psychiatric applicants, but things are changing. In fact, the number of psychiatric residents has increased by 21% in recent years, and by 2022 there are nearly twice as many applicants for slots.
Gih indicates an alternation of generations. “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. , human capacity to function, and their place in society,” he says.
“Creating new residency slots is very important. After all, it’s the only way to get more psychiatrists.”
Art Walaszek, M.D.
University of Wisconsin School of Medicine and Public Health
Of course, any residency program needs to attract and retain faculty. Walaszek says that’s difficult because academia is more bureaucratic and pays less than private schools. “It’s important to find ways to deal with burnout and increase flexibility. Otherwise, faculty may cut their hours or leave the office altogether.”
If so, Walaszek says the field will face problems. “These are the resources we need to train future psychiatrists and get medical students excited about 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 portion (5%) of overall care, the proportion of mental health services provided by telemedicine remains high at 40%.
This is notable because virtual clinics can also help expand the workforce, according to experts.
said Matt Mishkind, Ph.D., assistant professor of psychiatry at the University of Colorado Anschutz Medical Campus. in Aurora. It also helps reduce burnout by shortening commute times and providing healthcare providers to a diverse range of patients who otherwise could not be treated, experts say.
Extending services to underserved communities is one of the biggest benefits of telemedicine, says a health psychiatrist at the University of California, San Diego, who treats many patients remotely in Southern California. said Jessica Thackaberry, M.D., Ph.D.
Some patients with Suckerberry disease live in areas where psychiatric care is not available, while others have traveled to Mexico seeking treatment. She says it can be life-changing.
“I had one patient whose anxiety was driving him into action. He would have ended up in an inpatient facility far from his family. We were able to keep him at home with a proper medication adjustment.”
Such care is feasible thanks to the flexibility of recent telemedicine regulations. Medicare, for example, lifted some telemedicine payment restrictions during the pandemic, and some changes were made permanent. We continue to monitor other obstacles, such as states ending pandemic-related exemptions.
Meanwhile, other professionals are exploring additional digital means to expand access to care.
One option is an online, self-paced module of cognitive behavioral therapy (CBT). This type of tool not only increases patient access, but also frees up time slots for providers. “A patient may meet with a provider for 20 minutes instead of 50 minutes after doing his CBT training, so the therapist sees two patients in the time available to see one. Mental health apps that help expand access are also proliferating, but Mishkind notes that their quality varies.
At Emory Healthcare in Atlanta, Brandon Kitay, MD, PhD wants to combine access and quality by bringing mental health apps in-house. Digital, which Emory has implemented with the help of outside technology companies, his platform collects patient data to monitor their needs, provide voluntary treatment, and allow providers to easily to provide you with comprehensive online support.
Kitay says 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 extend care, we should try this.”
collaboration that matters
Experts say that if we want to help as many patients as possible, we need to reach out to where patients often come: primary care offices. In fact, nearly 60% of his patients who receive mental health treatment receive treatment from her PCP.
Among the various options for delivering psychiatric expertise through PCP offices, the evidence-based collaborative treatment model is often the approach of choice.
Here’s how it works: A PCP screens patients for anxiety and depression. Academics or social workers) can take the patient. In general, the care manager provides care, monitors patient progress, and proactively reaches out to patients who are not improving.The PCP team regularly (usually once a week) I have consulted with a psychiatrist to obtain information such as medication management.
“In my psychiatric clinic, I can see one patient an hour, but with collaborative care, I can help treat 10 to 12 patients at the same time,” says the university’s psychologist. said Rachel Weir, M.D., Ph.D., Chief Health Integration Officer. of Utah Health in Salt Lake City. “This is a very dramatic expansion of access.”
For UW’s Ratzliff, one of the benefits of this 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 physical examination. The patient saw the BCM the same day and was immediately put on medication and treatment monitored by a psychiatrist.”It is unlikely that he would have been treated elsewhere,” Ratzliff said. increase. “The achievements of the patient’s mother [Collaborative Care] By saving her son’s life. ”
“We can see one patient an hour, but with collaborative care we can help treat 10 to 12 patients at the same time.
Rachel Weir, MD
University of Utah Salt Lake City
Some psychiatrists pursue other interprofessional options because establishing co-treatment can require significant infrastructure and training. This includes eConsults (electronic consultations), allowing experts to share their expertise in short remote exchanges.
At Emory, Kitay explains: There is a code for getting reimbursement for treatment costs, and the psychiatrist’s record becomes part of the patient’s medical record, so other health care providers can see it. ”
Leaders at the University of Utah Health are preparing to launch an electronic health record feature. This feature automatically provides treatment options to healthcare providers when a patient screens positively for mental health concerns. .
Support for PCPs also comes in the form of Project ECHO sessions offered by various teaching hospitals around the country. In these, a psychiatrist will discuss topics such as her LGBTQ+ mental health, and remote participants will not only learn from lectures, but also from discussing cases seen in practice. And there are phone lines where PCPs can get advice from psychiatric experts, for example, two years ago UW installed one that he runs 24/7.
In all this work, educators are also focused on training future psychiatrists to collaborate with their PCP colleagues. In fact, more than half of psychiatric programs report teaching trainees how to work with clinicians in other fields.
“We tell trainees that your role as a psychiatrist is no longer just to provide care to individual patients,” says Ratzliff. “An important part of your role is teaching and being a resource for your colleagues.”
