RESEARCH WEEKLY: The perilous shortage of psychiatrists

(Aug. 23, 2016) Serious mental illness (SMI) is associated with a multitude of consequences that can shorten and reduce the quality of life for those who have it. Arrest, incarceration, homelessness, victimization, violence including suicide, and a host of similarly catastrophic impacts fall disproportionately on the barely 3% of the population with schizophrenia and severe bipolar disorder.

In any given year, fewer than half the estimated 8.1 million of people with these psychiatric disorders in the United States receive treatment. Count among the many barriers to their treatment an acute and worsening shortage of psychiatrists, as a new report in Health Affairs details.

The federal government identifies Health Professional Shortage Areas (HPSAs) based on the ratio of physicians to residents in specific geographic areas. Mental health HPSAs are based on the ratio of psychiatrists to residents. There are approximately 4,000 of these HPSAs in the country. The federal Health Resources and Services Administration estimates only half of them have enough psychiatrists to meet demand.

Three Questions of Supply
The title of the paper spells out the result: “Population of US practicing psychiatrists declined, 2003-13, which may help explain poor access to mental health care.” In the study, Tara F. Bishop and colleagues take on three questions:

• Did the supply of psychiatrists change from 2003 to 2013 and, if so, how much compared with other specialties?
• What regions of the country have the largest and smallest supplies of psychiatrists, per capita?
• What population characteristics are associated with psychiatrist supply?

The research team found that the average number of psychiatrists per 100,000 residents dropped by 9% during the 10-year period, after adjusting for population growth. By comparison, the average number of neurologists increased by 20% and the average number of primary care physicians – also considered a low-supply specialty – increased by nearly 2%. The population-adjusted number of total physicians in the United States grew by 4%, while the number of psychiatrists dropped 0.2%. The reduction “likely limits patients’ access” to psychiatric services,” the authors said.

Shortages were not geographically distributed. New England enjoyed the highest concentration of psychiatrists at 24.5 per 100,000 residents, while the Pacific region was served by barely half that many: 13.3 per 100,000 people. Of all physician specialties analyzed, psychiatrists were the most unequally distributed by region. Their distribution was influenced by regional education and income with greater psychiatrist supplies in areas with more high school graduates and higher household income. Areas of low population density also may be at “high risk” of shortages, they said.

Implications of Shortages
“The concern is that if this trend continues, access will worsen over time,” the authors conclude. Other mental health professionals – psychologists, psychiatric nurses, social workers and others – are believed to make up 95% of the mental health workforce and also serve psychiatric patients, they said, “However, psychiatrists – because of their medical training and ability to prescribe medications – provide different care than these other providers do.”

Among the implications of psychiatrist shortages noted by the authors:

• The supply of psychiatrists “likely limits” access to services by people with serious mental illness and threatens mental health parity as required by the Mental Health Parity and Addiction Equity Act of 2008. It is likely to grow worse unless addressed.
• Policymakers, payers and the community need to develop strategies to recruit and retain psychiatry specialists. Among these is addressing compensation for psychiatrists, among the lowest-paid specialties.
• Because of how much time it would require for such strategies to begin filling the gap, alternative treatment models need to be explored for providing psychiatric care. These include coordinated care practices, in which psychiatrists serve as consultants to primary care physicians or other mental health professionals, and new technologies such as telemedicine, mobile health and computer-based interventions.

References:
Bishop, T.F. (July 2016). “Population of US practicing psychiatrists declined, 2003-13, which may help explain poor access to mental health care.” Health Affairs.