One out of every 5 people in the United States had a mental illness in 2019 — a total of 51.5 million people. Then COVID-19 struck.
Fear of contracting the deadly virus, the loss of loved ones, painful social isolation, economic setbacks, and other powerful stressors eroded the well-being of communities across the country. At the height of the pandemic, 40% of adults reported symptoms of anxiety or depression — compared with 11% pre-COVID. Over time, this percentage dipped to 33% in June 2022, still higher than pre-pandemic levels.
Yet the United States does not have nearly enough mental health professionals to treat everyone who is suffering. Already, more than 150 million people live in federally designated mental health professional shortage areas. Within a few years, the country will be short between 14,280 and 31,109 psychiatrists, and psychologists, social workers, and others will be overextended as well, experts say.
“We have a chronic shortage of psychiatrists, and it’s going to keep growing,” says Saul Levin, MD, CEO and medical director of the American Psychiatric Association. “People can’t get care. It affects their lives, their ability to work, to socialize, or even to get out of bed.”
In addition, the gap between need and access is wider among some populations, including those in rural areas. In fact, more than half of U.S. counties lack a single psychiatrist. In Nebraska, “you might have to wait months for an appointment — even for people who are fairly ill,” says Howard Liu, MD, MBA, a psychiatrist at the University of Nebraska Medical Center (UNMC) in Omaha.
Several factors fuel the shortage. “The U.S. population has grown, there’s a lot of mental health need especially with the pandemic, and we don’t have enough residency slots to train people,” says Anna Ratzliff, MD, PhD, psychiatry residency program director at the University of Washington (UW) in Seattle. There’s also a retirement drain since more than 60% of psychiatrists are 55 or older.
“People can’t get care. It affects their lives, their ability to work, to socialize, or even to get out of bed.”
Saul Levin, MD
American Psychiatric Association
In response to the dramatic need, leaders in the field are working hard to find effective solutions. Some are using telemedicine to meet patients wherever they are. Others focus on recruiting and training a fresh crop of psychiatrists.
And still others aim to educate and support primary care providers (PCPs), the frontline physicians who treat most mental health patients. Such a collaborative, interprofessional approach is crucial in filling the psychiatry gap, experts say.
The need for collaboration comes down to numbers, says Daniel Gih, MD, UNMC psychiatry residency director. “Even if every single medical student selected psychiatry, sadly, we would still be quite short in this country,” he says.
Turning out more psychiatrists
Although training more residents in psychiatry by itself won’t completely address rising mental health needs, it remains essential, experts say.
“Creating new residency slots is critical. After all, it’s the only way to produce more psychiatrists,” says Art Walaszek, MD, a psychiatrist at the University of Wisconsin School of Medicine and Public Health in Madison who co-authored a 2021 study on the issue.
But providing residency training is costly, and government funding is limited. In 2020, legislation increased Medicare-supported residency slots for the first time in decades. The move added 200 slots annually for five years, spread across the nation and all medical specialties. In addition, the proposed Resident Physician Shortage Reduction Act, if enacted, would add another 2,000 annually for seven years. Mostly, though, individual institutions foot the bill for any new psychiatry slots.
Sometimes, residency expansion means increasing spots in existing programs. Sometimes, it involves creating brand-new programs.
Building a new program is no minor matter. “There are many accreditation rules and regulations to learn. You also need to figure out how to give [attending] physicians time for the educational and administrative work of training. It’s like managing a small workforce,” says Gih.
At UW, which recently added 16 more psychiatry slots, expansion includes building a new behavioral health teaching facility with larger rooms to accommodate more trainees. The slots and the building are thanks to state dollars, another common source of residency funding.
The question then arises: If you build it, will students come?
In the past, attracting psychiatry applicants was somewhat challenging, but that’s been changing. In fact, the number of psychiatry residents has risen 21% in recent years, and in 2022 there were nearly twice as many applicants as slots for them.
Gih points to a generational shift. “People now want careers that offer better work-life balance. They also want to work in disciplines where they can look at patients more holistically. They are thinking more about issues like trauma, social justice, and a person’s ability to function and their place in society,” he says.
“Creating new residency slots is critical. After all, it’s the only way to produce more psychiatrists.”
Art Walaszek, MD
University of Wisconsin School of Medicine and Public Health
Of course, any residency program needs to attract and retain faculty. That can be tough because academia can involve more bureaucracy and less income than private practice, says Walaszek. “It’s important to find ways to address burnout and increase flexibility. Otherwise, faculty may reduce their hours or leave entirely.”
If they do, the field faces trouble, Walaszek says. “These are the people we need to train future psychiatrists and to get medical students excited about a career in this field.”
As in other medical fields, the pandemic pushed mental health care online. But while telemedicine reverted to a slim segment of overall care — 5% — the proportion of mental health services provided via telemedicine has stayed high — at 40%.
That’s noteworthy since virtual care can also help extend the workforce, experts say.
“Telemedicine lets you get away from the confines of a brick-and-mortar clinic that’s open 8 to 5, so you can work expanded hours,” says Matt Mishkind, PhD, an assistant professor of psychiatry at the University of Colorado Anschutz Medical Campus in Aurora. It also can help reduce burnout by cutting commute times and offering providers diverse patients they otherwise couldn’t treat, experts say.
Extending services to underserved communities is one of telemedicine’s greatest benefits, says Jessica Thackaberry, MD, a UC San Diego Health psychiatrist who remotely treats many patients in Southern California.
Some of Thackaberry’s patients live in areas with no access to psychiatrists, and some have traveled to Mexico in search of care. For such individuals, telemedicine can be life-changing, she says.
“I had one patient whose anxiety was causing him to act out. He would have wound up in an inpatient facility far from his family. But by seeing him via tele-psychiatry, I was able to make a simple medication adjustment and keep him at home.”
Such care is feasible thanks to recent flexibilities in telemedicine rules. For example, Medicare lifted several telehealth payment restrictions during the pandemic, and some of the changes have been made permanent. But experts continue to monitor other obstacles, including states ending pandemic-related waivers that enabled out-of-state physicians to provide telehealth.
Meanwhile, other experts are exploring additional digital means for expanding access to care.
One option is online, self-paced modules for cognitive behavioral therapy (CBT), an approach backed by a growing body of research, says Mishkind. This type of tool not only increases access for patients — it also opens up provider timeslots. “The patient might do their CBT training and then meet with the provider for 20 minutes instead of 50, so the therapist sees two patients in the time they could just see one.” There’s also a proliferation of mental health apps that could help expand access, but Mishkind notes that their quality is uneven.
At Emory Healthcare in Atlanta, Brandon Kitay, MD, PhD, hopes to combine access and quality by bringing a mental health app in-house. The digital platform — which Emory is implementing with the help of an external tech company — will capture patient data to monitor need, provide self-directed therapy, and allow providers to offer brief online support, among other services.
Emory’s app should be ready to roll out within a year and will undergo two years of research in a pilot project, says Kitay. “We need to see if this will work well, but this is the kind of thing we need to try if we are going to expand care.”
If you want to help as many patients as possible, experts say, you need to reach them where they tend to show up: primary care offices. In fact, nearly 60% of patients who receive mental health treatment do so from their PCP.
Among the various options for offering psychiatric expertise through PCP offices, the evidence-based Collaborative Care Model is often the favored approach.
Here’s how it works: A PCP screens a patient for anxiety or depression. Following a positive result, the physician can walk the patient down the hall to a behavioral care manager (BCM) — usually a psychologist or social worker — who can further explore the patient’s symptoms. Generally, the care manager provides therapy, monitors patients’ progress, and proactively reaches out to those who aren’t improving. The PCP team consults regularly — usually once a week — with the affiliated psychiatrist to get such inputs as medication management.
“In my psychiatry clinic, I can see one patient in an hour, but using Collaborative Care, I can assist with the treatment of 10 to 12 patients in the same time,” says Rachel Weir, MD, chief of mental health integration at University of Utah Health in Salt Lake City. “That’s a very dramatic expansion of access.”
For UW’s Ratzliff, one of the model’s benefits is getting patients necessary care quickly. She recalls one physician who noticed signs of depression in a patient during a physical. The patient met with the BCM the same day, and soon was receiving psychiatrist-monitored medication and therapy. “It’s unlikely he would’ve gotten treatment elsewhere,” says Ratzliff. “The patient’s mother credits [Collaborative Care] with saving her son’s life.”
“I can see one patient in an hour, but using Collaborative Care, I can assist with the treatment of 10 to 12 patients in the same time. That’s a very dramatic expansion.”
Rachel Weir, MD
University of Utah Health in Salt Lake City
Establishing Collaborative Care can require fairly significant infrastructure and training, so some psychiatrists pursue other interprofessional options. These include eConsults — electronic consultations — that allow specialists to share expertise in brief, remote exchanges.
At Emory, explains Kitay, “We established a mechanism for answering questions that’s formal, rather than a hallway conversation between doctors who happen to know each other. There’s a code to get reimbursed for one’s time, and the psychiatrist’s notes become part of the patient’s medical record so other providers can also see it.”
At University of Utah Health, leaders are getting ready to launch an electronic health record feature that will automatically offer providers treatment options when patients screen positive for mental health concerns — “rather than just, ‘You figure out what to do,’” says Weir.
Support for PCPs also comes in the form of Project ECHO sessions that various teaching hospitals across the country offer. In these, a psychiatrist presents on a topic such as LGBTQ+ mental health, and remote participants learn from the lecture as well as from discussing cases they’re seeing in their practices. And then there are call lines where a PCP can get advice from a psychiatric expert. For example, two years ago, UW set up one that runs 24/7.
In all this work, educators are also focusing on training future psychiatrists to collaborate with their PCP colleagues. In fact, more than half of psychiatry programs reported teaching trainees how to work with clinicians from other disciplines.
“We’re telling trainees that your role as a psychiatrist is no longer just to provide care for individual patients,” says Ratzliff. “A significant part of your role is to teach and be a resource for colleagues.”