Bridging the Mental Health Provider Gap

With more people reporting symptoms of anxiety and depression, clinicians are struggling to meet the demand for help. In this Psychiatric Times article, Elisabeth Netherton, MD, highlights the reasons why and warns the situation could get worse.

The mental health provider shortage could not be happening at a worse time. It was already a problem that has been decades in the making, but the COVID-19 pandemic has sent everything into overdrive.

In 2020, 38% of adults in the United States reported symptoms of anxiety or depression, up from just 11% in 2019. Emergency departments have seen more individuals seek treatment for suicide attempts, drug overdoses, domestic violence, and child abuse and neglect.

The demand for mental health care may be rising, but the supply of providers has been lagging for years. Back in 2013, a deficit of more than 6000 psychiatrists was projected for 2025, representing 12% of the workforce. Today, that estimate has been pushed to more than 7500. And it is not just happening in the mental health field: More than 15,000 primary care and 11,000 dental health providers are needed to bridge care gaps in their specialties.

For mental health providers, there are more reasons for the shortage than solutions. Certainly, increased awareness and better screening have boosted people’s confidence to seek treatment. There are internal reasons: recruitment challenges, an aging workforce, and provider burnout. There are also external forces: a biased insurance reimbursement system and lingering stigma around psychiatry and mental health.

Provider shortages by the numbers

We know that our patients are differentially impacted by this shortage. While one-third of all Americans lack adequate access to mental health care, this tends to be much higher in rural and partially rural areas of the country. In Wyoming and Utah, for example, 96.4% and 83.3% of the population live in provider shortage areas, respectively, compared to 0.4% in New Jersey and 4% in Massachusetts.

A patient’s choice of psychiatrist is highly personal—maybe more so than other types of physicians. For example, women with histories of sexual trauma often prefer to meet with female psychiatrists. The severity of shortages in many areas of the country prevents patients from exercising their ability to choose the right provider for them, directly impacting their care experience.

Patients are also challenged by long wait times for treatment. Those who do get an outpatient appointment often have to wait several months. During this wait, many are lost to treatment or resort to seeking care in emergency rooms. In 2016, 1 in 5 adults reported that they were suffering from mental illness, yet less than 50% of them received treatment. In 2017, the average wait time to receive emergency psychiatric care was 23 hours.

Psychiatrists also face challenges from the shortage, including pressure to fit more patients into their tight clinic schedules. Many psychiatrists find their appointments becoming shorter to accommodate more patients. But this only prevents in-depth clinical assessment, collaboration with treatment team members, and consultation with primary care providers we rely on.

With shorter appointments, there is a greater chance of overprescribing antipsychotics and other medications. It takes a great deal more time to educate patients about the need to subtract medications than it does to add new ones. Additionally, the length between prescription refills may be extended beyond a provider’s ability to monitor responses and side effects.

Stretched too thin, these scenarios set the stage for provider burnout. Physicians in general have high rates of burnout, with 45.8% of physicians reporting at least one symptom. Psychiatrists experience a unique kind of stress, as they “use themselves as tools” to treat patients. This can be exacerbated by long hours, managing suicidal or homicidal patients, and poor work-life balance. Unmanaged, this stress can drive psychiatrists to feel the need to rescue patients, to feel like failures if treatment is not effective, to feel powerless against illness, or to fear becoming ill themselves.

Psychiatry is a challenging profession that still suffers from stigma. It is often viewed negatively by other medical professionals and seen as remote from other forms of medicine—an unscientific specialty lacking in glamour or prestige. That many medical students’ exposure to psychiatry is limited to emergency medicine and inpatient psychiatric hospitals further exacerbates this stigma. It is a view that continues to challenge recruitment efforts during medical school.

After World War II, 7% to 10% of medical students chose psychiatry as their specialty. But the closures of state-run psychiatric hospitals and the sidelining of care for the seriously mentally ill took a toll. By the 1970s, this rate fell by half and has fluctuated between 3% and 5.5% ever since.

Students are often pulled to psychiatry for deeply personal reasons. Perhaps they witnessed a family member suffer from mental illness. Perhaps their interest was piqued by a previous degree in psychology, an inspiring teacher, or an exceptional clinical placement. While it is reassuring to see medical students have that “lightbulb” moment, there is an opportunity to encourage more students to enter medical school because of the power of psychiatry.

Insurance’s trickledown effect

Insurance has long dragged its feet on adequately covering mental health care. Patients are three to six times more likely to receive out-of-network mental health care providers and facilities than other medical and surgical services. Reimbursement policies for health insurance companies can be so daunting that 40% of psychiatrists in 2017 operated cash-only private practices, second only to dermatologists.

Historically, insurance companies tend to favor physical health care needs over mental health. Although it is unthinkable for anyone to suffer long from a broken ankle, individuals with serious mental illnesses often have to wait months for treatment. Insurance companies work additional legal loopholes by requiring patients to meet a high bar of criteria to qualify for treatment. Often, this means only patients who are very ill qualify for care coverage.

While federal and state parity laws seek to balance coverage, insurance companies often skirt this requirement by shrinking provider networks. As a result, patients wait longer to receive treatment and have fewer options when selecting a provider. Those who do have in-network options often have to wade through outdated insurance databases or “ghost networks” filled with providers who do not even take insurance, had disconnected numbers, or had died.

A number of laws have worked to close the gaps in coverage. Passed in 2008, the Mental Health Parity and Addiction Equity Act (MHPAEA) required insurance companies to reimburse mental health conditions in a manner similar to other medical conditions. This law sought to patch previous legislation that allowed limits on facilities and treatment visits as well as higher copays for outpatient mental health visits. The law also expanded coverage to include substance abuse treatment.

Resolving the provider shortage

Recruitment and workforce development: Prioritizing recruitment; mentoring; and longer, hands-on training residencies is vital in giving students ample opportunity to explore psychiatry. Expanding these opportunities into rural areas may also encourage students to remain in these areas after graduation.

Telehealth: Telehealth holds enormous potential for giving access to hard-to-reach patients, especially those living in rural areas. During the pandemic, federal and state governments eased hundreds of restrictions to allow patients access to telehealth care via video-conferencing services. However, these are temporary measures. Because each state differs in how it legislates and regulates the practice of medicine and telehealth, there are limits to how far these services can extend.

Collaborative care model exploration: It is becoming increasingly clear that mental health and physical health are linked. Through a collaborative care model, psychiatrists serve as team leaders in a primary care setting where the holistic needs of patients are taken into account and treated collectively. This is especially effective with patients who are suffering from cooccurring medical and behavioral health conditions.

Stigma reduction: Eventually, psychiatry’s success lies in its ability to partner with other medical specialties. We need to capitalize on the growing understanding that, ultimately, mental health is physical health.

Insurance reimbursement system improvement: Forty percent of psychiatrists do not accept insurance highlights the growing gap between the cost of services and reimbursement amounts. This requires diligence on the part of providers to continue to negotiate fair market rates.

Regulatory barriers and opportunities: While federal regulations guide the big picture, there is room to improve legislative consistency across the states. But states can apply their own, more restrictive measures to create a firewall and limit collaboration between behavioral health and primary care providers.

Read the full Psychiatric Times article with sources.