Fearing she may be depressed, a young woman calls a psychiatrist. She’d like to be seen right away and is disappointed to learn she needs to wait a week. But she’s actually quite lucky. Elsewhere, she might wait weeks or even months to get an appointment with a mental health professional—or travel hundreds of miles from home to find the closest practitioner.
The United States is suffering from a dramatic shortage of psychiatrists and other mental health providers. And the shortfall is particularly dire in rural regions, many urban neighborhoods, and community mental health centers that often treat the most severe mental illnesses.
“The shortage of psychiatrists is an escalating crisis,” notes the physician search firm Merritt Hawkins in a 2017 report. “[The gap is] of more severity than shortages faced in virtually any other specialty.”
Darrell G. Kirch, MD, a psychiatrist and AAMC president and CEO, points to some of the key concerns. “We face a broad range of mental health issues, including the acute problems of opioid addiction and increasing rates of depression and suicide,” says Kirch. “I think one of the great tragedies is that some of the most seriously mentally ill individuals are homeless or are caught in a revolving door between prison and the street,” he adds.
Across the country, medical schools and teaching hospitals are taking a variety of measures to address the shortage, including recruiting more future psychiatrists. Efforts show signs of progress: For example, from 2010 to 2015, the number of new psychiatry residents grew 5.3%, according to AAMC data. And institutions are working to develop innovative ways to help the existing pool of psychiatrists reach a greater number of people in need of care.
The growing mental health shortage
In the United States, nearly one in five people has some sort of mental health condition. And the disease burden of mental health and substance use disorders was higher than for any other condition in 2015, reports the Journal of the American Medical Association.
“Our whole society is affected by untreated mental illness,” says Anna Ratzliff, MD, PhD, associate professor of psychiatry at the University of Washington (UW) School of Medicine. “It affects people's ability to work, build relationships, and contribute to their communities.”
What’s more, the need for treatment is expected to rise as the number of psychiatrists falls. In 2025, demand may outstrip supply by 6,090 to 15,600 psychiatrists, according to a 2017 National Council for Behavioral Health report that explores the shortage’s causes and suggests solutions.
A number of factors fuel the shortage, including a greater awareness of mental health problems that has spurred people to seek treatment. Also, mental health providers frequently are reimbursed less than physical health providers, a 2017 report notes, leaving institutions sometimes struggling to cover salaries. And then there’s a retirement drain: More than 60% of practicing psychiatrists are over the age of 55—one of the highest proportions among all specialties, AAMC 2015 data indicate.
“Our whole society is affected by untreated mental illness. It affects people's ability to work, build relationships, and contribute to their communities.”
Anna Ratzliff, MD, PhD
University of Washington School of Medicine
Ratzliff suggests another possible cause. “Stigma and misunderstanding of mental illness have led to insufficient attention to this issue,” she believes. “I don't think we'd ever say to someone, ‘I‘m sorry, but only one in 10 people with cancer will be able to see a cancer specialist.‘ I don't think people would tolerate that.”
Recruiting tomorrow's psychiatrists
At the University of Nebraska Medical Center (UNMC), efforts to recruit future psychiatrists have produced impressive results. Since 2013, the percentage of UNMC students choosing psychiatry has more than doubled. It's also more than twice the national average.
What's behind the success? As research elsewhere suggests, the top factor is a high-quality medical school psychiatry clinical rotation, notes Howard Liu, MD, UNMC associate professor of psychiatry. Seven years ago, UNMC established a psychiatric teaching clinic to give students more hands-on experience working with patients under the direct observation of faculty, who provide in-depth feedback.
In addition, “we created a strong culture of mentoring," says Liu, who hosted networking events in his home until the crowd outgrew the space. “Students need to meet engaged psychiatric faculty to see if they can imagine themselves in that life and that work.”
Mentoring also is part of efforts by the Behavioral Health Education Center of Nebraska, an interprofessional workforce group embedded at UNMC, to increase the number of Nebraska's rural mental health providers. For example, rural high school and college students have videoconferenced with psychiatry residents three times a month, discussing everything from MCAT preparation to work-life balance.
At the University of New Mexico (UNM), a dedicated track helps prepare—and attract—psychiatry residents to practice in rural areas. The program spans all four years, with senior residents working at tribal clinics and community mental health centers two days each week for at least six months. Nearly 40% of rural track residents ultimately practice in rural New Mexico, compared with 10% of other UNM psychiatry residents, according to a study published in 2014.
“We created a strong culture of mentoring. Students needs to meet engaged psychiatric faculty to see if they can imagine themselves in that life and that work.”
Howard Liu, MD
University of Nebraska Medical Center
Elsewhere, some institutions are adding residency slots to help increase the numbers of psychiatrists, notes Carlyle Chan, MD, AAMC senior consultant in graduate medical education. “Part of the problem is that Medicare stipends for residency positions were frozen in 1997,” he explains. “So some hospitals have taken on the added training costs themselves.”
Increases in residency numbers are encouraging, notes Tristan Gorrindo, MD, director of education at the American Psychiatric Association (APA). Yet, he adds, “a few thousand total residents each year are not adequate given growing demand and the numbers of psychiatrists moving into retirement. We also need to look at training providers to work in different ways to solve this problem.”
New models of mental health care
Telepsychiatry—including videoconferencing for patient evaluation, medication management, and therapy—is one effective way to deliver more care to remote areas, says James Shore, MD, an associate professor of psychiatry at the University of Colorado School of Medicine who has expertise in telemedicine.
“Telemedicine also expands the workforce,” Shore adds, “in that it offers the flexibility to work from home or in circumstances when practitioners otherwise might not be available. Also, access to more varied client populations can decrease burnout and thereby increase workforce retention.”
In addition, telepsychiatry enables psychiatrists to advise primary care providers (PCPs), who are often on the front lines of treatment. For example, Project ECHO: Extension for Community Healthcare Outcomes, run out of the UNM medical school, connects specialists with PCPs seeking guidance on behavioral health treatment.
Such collaboration is essential, says APA’s Gorrindo, given that half of people who seek treatment do so in primary care settings. “We won't be able to do this without our colleagues,” he notes, “and with psychiatrists' support, they can become more sophisticated in their treatment.”
Another collaborative model, developed at UW, embeds psychiatrists in primary care practices, where they oversee cases, provide consultation, and see only the most challenging patients. A 2012 Cochrane Review of 79 studies on the approach, called Collaborative Care, noted its effectiveness in treating anxiety and depression.
Now the Centers for Medicaid and Medicare Services has invested $2.9 million to train 3,500 psychiatrists in this model. The sessions—available online or in person—are created by APA and the UW Advancing Integrated Mental Health Services Center.
UW’s Ratzliff says the team approach appeals to many psychiatrists interested in practicing differently or giving back to their communities in a broader way. “Feeling like you’re part of a learning, growing group is stimulating,” she says. “You may have some [of your own] patients that you have a longer relationship with, but a great complement to that is the powerful impact you can have supporting the care of an entire population.”
The potential impact on patients is what draws many to psychiatry, notes Kirch. “Whenever I encourage medical students to consider psychiatry, I point out that there are few specialties with such a rich range of opportunities to help patients who are in severe distress,” he says. And at the same time we are beginning—through brain imaging, genetics, and other techniques—to understand the biological basis of mental disorders, which creates the opportunity to develop more effective treatments. “This is an exciting time,” adds Kirch. “We have the opportunity to transform people's lives.”
