Robin M. Johnson, MD

Based on what we know right now, the US Supreme Court is poised to overturn 

, which allowed a patient and her doctor to make decisions about an abortion. According to the leaked initial draft abortion opinion, the states will decide,

 which likely means that some states will not allow abortion. Other states may allow exceptions for rape and incest. To me, it feels like the Supreme Court burst into the examination room and sat between the patient and her doctor. This is an intrusion into the doctor-patient relationship.

The Supreme Court may not know women who have serious mental illness such as borderline personality disorder, rapid-cycling bipolar disorder, or treatment-refractory depression. However, these disorders are important to consider when deciding to bring a child into the world. This decision takes the doctor completely out of the picture and forces the woman with a disability, with a chronic mental illness, or in poverty to follow the law or else.

Particularly for women with serious mental illness, 9 months is a long time. Many must take medications, and these may have an adverse effect on the pregnancy. They also often experience morning sickness, which will have an impact on the level of psychiatric medication and may result in an increase in symptoms. For example, when my patients with bipolar disorder begin to sleep less, the concern is that this may be the beginning of a significant increase in symptoms.

 It can be very difficult to sleep in pregnancy depending on how much the baby is moving, along with various other issues such as frequent urination and back pain.

 In addition, many chronically ill patients have symptoms even when they are appropriately treated on medications. Pregnancy can also be frightening; there are lots of sensations and discomforts that are not always easy to manage.

 All of this may result in patients needing to be hospitalized to keep them safe during this very challenging time.

With incredible support and resources, having a baby can be a very special experience. For example, I treated a young couple who both had serious mental illness. They married and were very excited about having a child. Both the husband’s and the wife’s parents came to the appointment, and the decision was made that the parents of the couple would lend incredible support. Both moms agreed to be available to go to all appointments and to handle calls if the couple was concerned. The moms also agreed to take turns staying with the couple after the baby was born, because babies do not sleep through the night. Despite this consistent support, there were a few emergency room visits and lots of doctor visits with medication adjustments. In the end, the couple moved in with one of the parents when the baby arrived.

Not all women have this level of support, however—especially now that 1 million individuals have died of COVID-19 in the United States.

 Some young women have lost partners, parents, siblings, aunts, uncles, and grandparents—the support system of other individuals in their family who could have helped them with a new baby. Without a support system to help, having a new baby can be a very trying experience, particularly for women with serious mental illness.

 decided that a woman and her doctor had the right to make this decision about an abortion—a clinical decision that would take into account the patient’s entire medical and mental health history. Now, 50 years later, the Supreme Court is set to overturn 

 removing the doctor completely from the equation and putting the states in charge of an important medical decision. Not only does this undermine the doctor-patient relationship, but will also have a particularly negative impact on patients with serious mental illness.

is a practicing psychiatrist in Atlanta, Georgia.

The opinions expressed are those of the author and do not necessarily reflect the opinions of

1. Gerstein J, Ward A. Supreme Court has voted to overturn abortion rights, draft opinion shows. 

https://www.politico.com/news/2022/05/02/supreme-court-abortion-draft-opinion-00029473

2. Jones I, Chandra PS, Dazzan P, Howard LM. 

Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period

Maternal infanticide associated with mental illness: prevention and the promise of saved lives

Sexuality, pregnancy, and childrearing among women with schizophrenia-spectrum disorders

5. Chuck E, Siemaszko C. Covid’s toll in the U.S. reaches a once unfathomable number: 1 million deaths. 

https://www.nbcnews.com/news/us-news/covids-toll-us-reaches-1-million-deaths-unfathomable-number-rcna22105

Articles

If Roe v Wade is overturned, how will patients with serious mental illness be affected?

 The Vanishing White Coat

The COVID-19 pandemic has exacerbated the psychiatry shortage, particularly in rural areas and small towns. Depression, anxiety, grief, and substance abuse have soared during the pandemic, but 111 million Americans live in a psychiatry shortage area, according to the US Department of Health and Human Services—and the current shortage of 6% is expected to be between 14,280 and 31,109 psychiatrists by 2024.

 The number of physicians entering specialties increased between 2003 and 2013; however, during that same period, the number of physicians entering psychiatry decreased by 0.2%.

Age may serve as an additional factor, as the average age of practicing psychiatrists is 55, the third oldest of all the specialties.

 Research shows that compensation of psychiatrists was a significant factor, particularly for young doctors.

 It is very likely that high-interest student loans in combination with low compensation has caused young doctors to select higher-paying specialties.

Clearly it is essential to have more psychiatrists, but how do we increase the psychiatry workforce to reach all the shortage areas in the country? Although the description of the shortage is clear, the solutions to the problem have not been. Without an intervention, the shortage is projected to continue until 2050. It is time to discuss some short-term and long-term solutions for the problem.

The internal medicine residency is 3 years, and the family medicine residency is 3 years—in contrast, the psychiatry residency is 4 years. With a lot of effort, pain, and imagination, the psychiatry residency could be shortened to 3 years. This would mean that fully trained psychiatrists would graduate every 3 years instead of every 4 years. This 1 change would increase the number of psychiatrists. This 1-year difference would be especially significant for the many young doctors who are carrying high-interest loans from college and medical schools, as a shorter residency would allow them to start paying down on their debt sooner.

If the residency remained 4 years as it is now, the final year of residency could be completely redesigned. That final year could become a year of mandatory clinical rotations in shortage areas, which are mainly rural and small towns. Allowing fourth-year residents—who are nearly fully trained psychiatrists—to provide psychiatric care in shortage areas under academic supervision would be an increase in the psychiatry workforce in areas where it is needed most. Many medical centers are in urban centers, so most residents have little or no exposure to rural or small-town practice. The most optimistic view is that some of the residents who practice in a small town or rural area will like the environment for reasons such as less traffic, lower cost of living, a slower pace of life, and/or lower taxes. Even if only a few residents decided to set up practice in one of these areas, it would be helpful.

The long-term solution would be to build medical schools with a focus on excellent clinical care in some of these rural shortage areas. Many medical centers are the engines of research in the country and in the world. Medical school faculty teach, but also treat patients. Medical students learn how to become doctors by seeing patients with supervision. Residents have clinics and are supervised, but provide a lot of clinical care during their training. Having medical schools nearby would bring a lot of care to the shortage areas, as the best and brightest from those areas may choose to attend medical school in the area in which they live. If these students remain in their hometowns to attend medical school and complete their residency, it would be a tremendous help to the psychiatry workforce. It also might be less expensive for medical students if they do not need to relocate to attend medical school or a residency program.

Although not discussed here, other medical specialties, such as primary care and pediatrics, are experiencing shortages, as well. Along with psychiatry, these 2 are also considered low-compensation specialties. Establishing medical schools in rural areas and small towns could also bring more primary and pediatric care options to patients in these shortage areas.

We have a tremendous amount of data about the psychiatry workforce shortage, and it is important to intervene to discuss ways to decrease it. What is needed now are solutions that can be implemented. The purpose of this discussion is to outline how decreasing the psychiatry residency by 1 year; mandating fourth-year rotations in rural and small towns that have a shortage; and building smaller medical schools in rural communities where the need is so great might serve as effective solutions. As a specialty, we need to have this conversation and intervene to increase the psychiatry workforce. The pandemic is making this more urgent, but it is also important for the future. Psychiatry has to act as soon as possible for the good of the nation.

is a practicing psychiatrist based in Atlanta, Georgia.

Addressing the escalating psychiatrist shortage

. February 12, 2018. Accessed December 15, 2021.
2. Harrar S. 

. Last updated June 2, 2021. Accessed December 15, 2021.

The Silent Shortage: A White Paper Examining Supply, Demand and Recruitment Trends in Psychiatry

 Merritt Hawkins. February 22, 2018. Accessed December 15, 2021.

The Psychiatric Shortage: Causes and Solutions

. National Council for Mental Wellbeing, Medical Director Institute. March 28, 2017. Accessed December 15, 2021.

The pandemic has worsened the psychiatry workforce shortage. What can we do about it?

Robin M. Johnson, MD

Articles

The Vanishing White Coat

Addressing Shortages in the Psychiatry Workforce