The Doctor Gap: Where Are All the Mental Health Care Providers?
Even in the midst of rising rates of suicide and substance abuse, nearly 117 million Americans live in what is known as "health professional shortage areas."
Put another way, only 27% of mental health needs in those areas are being met, according to the Health Resources and Services Administration (HRSA). More than 6,300 additional providers would be needed to erase the gap.
How did things get so bad?
The dearth of mental and behavioral health professionals -- psychiatrists, psychologists, marriage and family therapists and others -- is not a recent development. It has slowly snowballed since the 1980s when state psychiatric hospitals were deinstitutionalized.
"This has been a problem that's been building over decades and decades, and now we're at a crisis point," said Angela Beck, director of the Behavioral Health Workforce Research Center at the University of Michigan, in Ann Arbor.
Primary care physicians provide around half of all behavioral health services in the United States, Beck noted. "Unmet need," the metric that HRSA uses, refers to the more serious or complex issues that require a trained mental health provider.
"We've got demand going up," Beck said, "but we don't have a pipeline or a supply that's expanding to keep pace."
The Association of American Medical Colleges (AAMC) projects a shortage of 3,400 psychiatrists by 2032.
"We have an opioid crisis, we have an aging group of psychiatrists, and we need to have more behavioral health," said Dr. Janis Orlowski, AAMC's chief health care officer.
And the need goes well beyond physicians. Patricia Pittman, who directs the Mullan Institute for Health Workforce Equity at George Washington University, said what is also needed is psychologists and social workers -- professionals who make up "the heart and soul of the mental health workforce."
Part of the problem lies in pay scales. The national average salary of a mental health and substance abuse social worker clocks in at $49,630, according to the U.S. Bureau of Labor Statistics. Mental health counselors who help people with substance abuse, behavioral health, and mental and emotional issues bring in slightly less, an average of $44,630. In contrast, psychiatrists earn $220,380.
Child and adolescent mental health
America's youth may be bearing the brunt of the shortfall.
A 2019 report in the journal JAMA Pediatrics examined disparities in mental health care use. Among children with a mental health disorder, nearly half (49.4%) did not receive needed treatment or counseling from a mental health professional.
Almost 60% of young adults aged 18 to 25 with a serious mental illness reported an unmet need for mental health care in the past year, according to a 2018 national survey. The average for all adults was just over 45%.
About 9,000 child and adolescent psychiatrists currently practice in the United States. HRSA projects a surplus of 3,720 to 4,310 child and adolescent psychiatrists by 2030. But psychiatrists writing in the December 2019 issue of the Journal of the American Academy of Child and Adolescent Psychiatry stated that HRSA "severely underestimates" unmet need in the child, adolescent and young adult population.
Dr. Wun Jung Kim, director of child adolescent psychiatry at Rutgers University in New Jersey, is one of the statement's co-authors. He said the need for services is ballooning due to a concerning rise in suicidal thoughts, self-injurious behaviors, teen depression and the like. On the supply side, he believes that society's investment in mental health, in general, has not kept up with society's demands.
Dr. J. Wesley Boyd, an associate professor of psychiatry at Harvard Medical School and staff psychiatrist at Cambridge Health Alliance in Boston, said, "Parents of children who require mental services face enormous geographic disparities in the access to care. Child- and adolescent-trained psychiatrists overwhelming stick to urban areas and are simply not available in most rural parts of the country."
Boyd said financial obstacles also come into play. "Even if you're in an area where there are theoretically enough child psychiatrists, many, many of them do not take any insurance whatsoever," he noted.
So, how can the nation shore up an often stigmatized segment of health care? Studies point to the benefits of "interprofessional practice"-- a team-based approach to care. What's less clear is what the perfect team looks like.
At the University of Michigan, Beck is involved in developing a "minimum data set," a sort of common language for describing and assessing all the providers in the mental and behavioral health continuum -- from psychiatrists and psychiatric nurses to social workers and case managers.
"We're looking individually at each occupation and doing sort of a headcount approach to supply without looking at the whole system and thinking about how these teams interact," Beck explained.
Understanding how all the pieces fit together, she said, is a critical step toward improving access to quality mental and behavioral health care.
SOURCE: American College of Cardiology, news release, March 18, 2020
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