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Commentary | May 01, 2009

Planning the Future Mental Health Workforce: With Progress on Coverage, What Role Will Psychiatrists Play?

David J. Vernon; Edward Salsberg; Clese Erikson; Darrell G. Kirch

Academic Psychiatry 2009;33:187-192.

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Received January 9, 2009; accepted January 23, 2009. The authors are affiliated with the Association of American Medical Colleges. Address correspondence to David J. Vernon, Association of American Medical Colleges, 2450 N St. NW, Washington, DC 20037; dvernon@aamc.org (e-mail).

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After 12 years of struggle, the Mental Health Parity Act was signed into law in October 2008. This is a great accomplishment, and a key goal of the law is to help ensure access to needed mental health services. However, although coverage is necessary for access, it is not sufficient to ensure it. Another critical ingredient needed is an adequate supply of appropriately educated and trained health professionals. It is imperative to ask and assess whether an adequate supply of mental health professionals (of which psychiatrists make up a significant part) in the United States will be available to ensure future access to high-quality mental health services.

Over the past 20 years, the demand for physician services has increased as a result of a number of interrelated factors, such as the growth and aging of the population, increased effectiveness of medical treatments, and the public’s increasingly high expectations of the health care system’s ability to heal (¹). Over the past decade, the number of new physicians entering the workforce has increased only slightly over the same period (²). These trends, combined with the likelihood that more than one-third of active physicians are likely to retire in the next 10—15 years and that their replacements are unlikely to work as many hours as their predecessors, contribute to the growing concern regarding severe physician shortages (²). After considering these and many other factors, in 2006 the Association of American Medical Colleges (AAMC) called for a 30% increase in student enrollment at U.S. medical schools by 2015 in an effort to ameliorate the impending shortages.

While the AAMC analyzes the overall supply and demand for physicians, its policy is to let medical students, residents, teaching hospitals, and training programs decide specialty choice and to encourage additional workforce studies and data to help individuals make informed decisions. Without the advent of a centralized decision-making body that determines an individual’s specialty, the number of future residents is uncertain for any given medical specialty.

As a result, specialties need to periodically conduct comprehensive studies and continually track key indicators. Many specialties have conducted major workforce studies in the past few years, and it may be time for psychiatry to consider such a study (³). A 2003 paper on the psychiatric workforce (⁴), which cited the aging of the workforce and reductions in psychiatrist work hours, questioned whether growth in the supply of psychiatrists would be able to keep pace with demand for psychiatric services.

The overall workforce equation is very complex, and analyzing numerous variables is necessary to confront this complexity (⁵). The complexity does not diminish when performing specialty-specific analysis; therefore, the purpose of this article is to provide updated data on factors that should be considered in assessing the future supply, demand, and need for psychiatrists.

Key Supply Factors

The overall physician supply has grown significantly over the past 20 years, but currently one out of three physicians is 55 years old or older and most likely will retire in the not too distant future (³, ⁶). Physician supply will continue to increase, albeit slowly, over the coming decades as the number of new entrants into the workforce is projected to exceed the number of retirees, but the population will grow at a faster rate as well. Furthermore, physician full-time equivalencies are projected to decrease in the coming years, as the new generation of physicians may seek work-life balance that allows more time for family and other personal interests (⁷, ⁸). However, psychiatry can offer this balance, which can help the field attract new physicians and encourage those in practice to delay retirement. A number of key factors affect the psychiatrist supply and should be thoroughly studied as part of a detailed workforce analysis; five are briefly highlighted below.

Aging of the Workforce.

The number of psychiatrists has increased 26% over the past 20 years, growing from 32,724 in 1986 to 41,385 in 2006 (⁹, ¹⁰). One of two psychiatrists is 55 years old or older, however, making the psychiatry workforce the second oldest specialty workforce after preventive medicine (⁶). This could pose less of an immediate concern for psychiatry than it might for other specialties with an aging workforce. Recent data from an AAMC survey of physicians over age 50, conducted before the recent financial turmoil (which may lead doctors to put off retirement for longer than initially expected), suggests that psychiatrists are more likely to work past typical retirement age (³). A key reason for this could be the greater ability to work part-time in psychiatry than in most specialties (an interest that has been shown to increase as physicians age). In addition, two reasons often cited by physicians as important in the decision to retire—stress of practice and on-call responsibilities—are of less concern to psychiatrists, which could partially explain their willingness to remain in practice longer (³). It will be important to continue to track retirement patterns and identify incentives to encourage physicians to remain in practice beyond planned retirements.

Next Generation.

The younger generation of physicians is very interested in a balanced life, which could lead them to work fewer hours than their predecessors. According to an AAMC national survey of physicians under age 50, 71% of all respondents listed ability to balance work and personal life as very important in a desirable work setting (³). Psychiatry is generally perceived as being a lifestyle-friendly specialty. Along with radiology, anesthesiology, dermatology, and other specialties with regular work hours and limited on-call responsibilities, psychiatry is increasingly appealing to the younger generation of physicians (¹¹). Flexible scheduling and part-time work options interest this generation as well, and will be powerful recruitment tools for those seeking to attract younger physicians, including psychiatrists, to their practice.

Feminization of the Field.

The psychiatric workforce, 33.9% female and rising, has consistently had a higher percentage of women than the overall physician workforce (¹⁰). Women now outnumber men in psychiatric residency training programs (Figure 1). While the number of women is rising in all specialties, they comprise only 27.8% of the overall workforce and 44.4% of residents in training (¹⁰, ¹²). Historically, female physicians have worked fewer hours per week and have seen fewer patients per week than their male counterparts, which is something that must be factored into future workforce planning studies (¹³—¹⁵). It is important to remember, however, that both men and women will be seeking out more balanced lifestyles in the future (³, ⁷, ⁸).

Growth in Residency Positions.

In academic year 2007, 1,250 physicians entered first-year positions in Accreditation Council for Graduate Medical Education (ACGME)-accredited psychiatric residency programs, representing about 5.3% of all new residents in training. Between 2002 and 2007, the number of psychiatric residents increased 5.8% (¹⁶). This is encouraging; however, financing for graduate medical education is limited and competitive, and future funding is uncertain, which makes the likelihood of any significant increases in the number of psychiatric residency positions questionable.

Also of note, there has been an increase in interest by U.S. medical school graduates in psychiatry; between 2002 and 2007 the number of U.S. physicians training in psychiatry increased by 16.3% (¹⁶). International medical graduates (IMGs) have historically filled training positions not filled by U.S. graduates, including in psychiatry. While the overall number of IMGs training in ACGME programs has continued to grow over the past few years, this has not been the case in psychiatry. In the absence of an increase in psychiatric training positions, it is likely that IMGs, currently at 30.5%, will continue to be squeezed out of the field as a result of the increased interest by U.S. medical graduates (¹²). Over the past decade (Figure 1), the percentage of IMGs in psychiatric residency programs has decreased substantially (¹²). This could potentially affect access to psychiatric care for the underserved because the IMG workforce is more likely to treat Medicaid and minority patients (¹⁷).

Diversity of the Workforce.

Minorities are significantly underrepresented in the psychiatric workforce as in all other specialties. Despite significant efforts over the years to increase the number of minorities in medical school, there has been little growth, making it difficult to increase the diversity of any specialty. Unfortunately, it does not appear that the nonphysician mental health provider workforce is any more diverse than the psychiatric workforce (¹⁸).

Key Factors Driving Demand for Psychiatry Services

Several key factors indicate that there will be a significant increase in demand for psychiatric services. However, it is difficult to predict how much of the increased demand for mental health treatment will be directed toward psychiatrists as opposed to other health practitioners. A brief look at the six factors highlighted below should be informative.

Scope of Practice and Roles of Nonpsychiatrists

General medical specialists, defined as excluding mental health specialists and psychiatrists, are the health care providers most likely to treat patients with mental health disorders (¹⁹). However, primary care is projected to face serious shortages (²⁰). With a potential shortage of primary care providers, patients may turn to their psychiatrists for other medical care beyond mental health needs.

Furthermore, as Richard Cooper noted in his 2003 piece on the future of psychiatry, "psychiatry’s jurisdictional boundaries" present a challenge for workforce planning (²¹). While there are about 40,000 active psychiatrists, this pales in comparison to the more than 400,000 other clinically trained mental health professionals in practice today who provide therapy and counseling, including psychologists, social workers, advanced practice psychiatric nurses, counselors, marriage and family therapists, psychosocial rehabilitation workers, school psychologists, and pastoral counselors (¹⁸). A study of practice patterns in the treatment of mental health disorders found that three out of four patients who received any care for mental health issues were treated exclusively by other mental health specialists and did not see a psychiatrist (¹⁹).

It is clear that the scopes of practice of a number of mental health professions (including psychiatry) overlap, and are likely to overlap long into the future. However, what is important is that decisions concerning the scope of practice for each profession are not determined by specific profession self-interest, as a means to reduce expenditures, or as a result of poor preparation. These decisions should be formed by analyzing the best evidence available and established by careful and thoughtful planning.

Growth and Aging of the Population.

The nation’s population is projected to grow by 25 million persons per decade, and between 2000 and 2030, the number of Americans over age 65 will double from 35 million to 70 million (¹, ²²). Concurrently, the World Health Organization (WHO) predicts that depression will be the second most prevalent illness by 2030, trailing only heart disease. As a result, if current trends of mental health provider utilization remain the same, it is not a reach to predict that the demand for mental health services will increase based on population growth alone (²³).

Furthermore, as the baby boom generation ages, it is difficult to imagine that they would not take advantage of mental health services more than their parents had before them. In fact, demand for psychiatric services is already rising for all age groups, including the elderly (¹). Dementia-related admissions will likely play a strong role, particularly for the 85-and-older population (²⁴). A significant number of elderly, including many of those with dementia, will also seek care for depression. However, psychiatrists will not necessarily treat the brunt of these new cases if current practice patterns prevail because most elderly patients turn to their primary care physician for treatment of depression rather than seek care from a psychiatrist (²⁵).

Mainstreaming of Psychotropic Drugs.

As medications have improved in terms of their efficacy and specificity, they have also gained more of the public’s trust, been used effectively by more individuals, and have achieved new levels of social acceptance (²⁶). Patients in 2002 were 4.5 times more likely to receive pharmacotherapy for depression compared to patients in 1987, but half as likely to receive psychotherapy (²⁶). With pharmaceutical companies producing medications at a rapid pace, there will certainly be expectations for more medical breakthroughs and for medications to be more efficacious and farther reaching for mental illness. Treatment patterns for depression are changing, making it difficult to predict what the net effect will be on demand for psychiatric visits. On the one hand, more people are seeking psychotropic treatment for mental health issues from physicians, including psychiatrists; but on the other hand, these patients are making fewer psychotherapy-related visits.

Insurance Coverage/Payment.

Expanding availability of third-party payment for mental health services contributed to the increase in treatment of depression (²⁶). If barriers to mental health are removed as a result of the recent passage of the Mental Health Parity Act (which goes into effect January 1, 2010) or other health care reform, demand for mental health services will likely increase, although states that have enacted mental health parity legislation continue to trail the rest of the nation in terms of psychiatric service demand (²⁷). It appears that any alterations in coverage or payment will have a difficult-to-predict—yet potentially drastic—effect on the psychiatry workforce.

Changing Utilization Patterns by Subpopulations

Latinos make up the fastest-growing segment of the U.S. population. According to the U.S. Census Bureau, 50% of total U.S. population growth between 2000 and 2004 occurred as a result of persons of Latin origin (²³). Studies have shown a greater unmet need for drug and alcohol treatment and mental health services in these populations than in white non-Latino populations and that Latinos may be experiencing higher levels of depression relative to other ethnic groups (¹, ²⁸). If Latinos become more acculturated in subsequent generations, it is likely that this booming population will increasingly seek out mental health services. One further wrinkle to consider is whether a lack of a diverse psychiatry workforce will hinder this subpopulation from seeking needed psychiatric care.

Subspecialty Shortages.

Some subspecialties within psychiatry are also facing shortages. The American Academy of Child and Adolescent Psychiatry (AACAP) reports that a current shortage in the number of child and adolescent psychiatrists exists both nationally and in every state. Moreover, according to an AACAP workforce fact sheet, a Bureau of Health Professions report predicts that the need for these psychiatrists will grow 100% by 2020 (²⁹).

The geriatric psychiatry workforce is facing similar problems. A recent study defined psychiatrists with geriatric caseloads greater than 20% as high geriatric providers. Between 1982 and 1996, the percentage of psychiatrists labeled high geriatric providers rose from 7.3% to 18.1%, respectively (³⁰). These data indicate increased demand for psychiatric service in age groups consistent with the baby boomer generation and a concern that shortages in psychiatry subspecialties can create dour situations.

Other psychiatry subspecialties such as addiction psychiatry, forensic psychiatry, and psychosomatic medicine could benefit from a comprehensive study which considers the supply and demand factors for these subspecialties. Analytically, these types of studies have been especially difficult due to the small size of the subspecialties, as data have usually been limited. Additionally, changes in care patterns and policies can have major effects on these subspecialties, which further complicate workforce analyses.

The importance of a thorough psychiatry workforce analysis highlights the need for a strong research effort concerning the psychiatry subspecialties. The subspecialty-specific research must be an important component of any future workforce planning initiatives. Clearly, not only is a specialty-specific analysis of the factors that affect supply and demand important, but an understanding of how these factors affect subspecialties is crucial so that one may grasp the entire psychiatry workforce picture.

Planning for the Future.

When forecasting the future demand for and predicting the future supply of psychiatrists, there are many unknowns and uncertainties. As indicated above, efforts to evaluate a specialty workforce must be approached with careful thought and consideration. It is an appropriate time to consider creating an in-depth psychiatry-specific workforce study that assesses the many factors highlighted above. Organizing and conducting such a study could take several years, and several more years to implement any findings. Add to that the needed years of training to produce a psychiatrist, and the importance to act sooner rather than later is clear.

While there is no crystal ball at our disposal, a good workforce study considers a variety of possible future scenarios. This helps the specialty, and the community at large, to understand the forces likely to drive future supply and demand. These efforts will allow psychiatry—and the medical field in general—to be realistically prepared for the predicted physician shortages. This important work is essential for ensuring that patients can receive timely and appropriate care from health professionals, best suited to give it.

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FIGURE 1. Percent Female and International Medical Graduates in Psychiatric Residency Training Programs

Source: JAMA Medical Education Issues (1997—2008), Appendix II, Table 2

Acknowledgments

Acknowledgments | References

The authors would like to thank Stacey Schulman, M.A., Michael McManus, and Susan Monseur, B.S., for their help in the preparation of this article. At the time of submission, the authors disclosed no competing interests.

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