Preparing for the Future: The Psychiatric Workforce

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Mental health care in the US is falling short. According to the most recent National Survey on Drug Use and Health, 23.8% (approximately 6.2 million of 27.1 million adults aged 18 years and older) with any mental illness perceived an unmet need for treatment in the previous year.^1,2

Other data indicate that approximately 60 million Americans struggle with mental health, and more than one-third of the US population lives in a Mental Health Professional Shortage Area.^2-5 Barriers to care are complex and involve patient-level factors (eg, stigma, affordability, geographic location) and provider-level factors (eg, reimbursement issues, restrictive scope of practice, clinician burnout).³ By most estimates, only half of people who struggle with mental health will ever seek psychiatric services.⁴

Although the greater mental health care team may include many professionals, such as psychologists and social workers, the burden of addressing serious mental illness falls on the prescribing professionals, such as psychiatrists, psychiatric nurse practitioners (NPs), and physician assistants (PAs). The diverse educational backgrounds bring complementary perspectives, strengths, and weaknesses that, when working together, can enhance the quality of care for patients and extend the reach of psychiatric services to underserved populations while maintaining quality and appropriate care.

Roles and Contributions in Behavioral Health

Because psychiatrists, psychiatric NPs, and psychiatric PAs can assess patients, diagnose psychiatric conditions, prescribe medications, and provide counseling or psychoeducation, there is considerable overlap in day-to-day duties. However, there are important differences in the typical focus of their practice, stemming partly from training and partly from legal scope (Table 1).⁶

TABLE 1. The Prescribing Psychiatric Clinicians

Medication management comprises a large portion of the workload for the prescribing professions, with each aiming to use medications judiciously to stabilize symptoms and improve patients’ functioning. The difference lies in prescribing authority: Psychiatrists have full authority, whereas NPs and PAs have prescribing authority in all 50 states, with some state-by-state restrictions for physician collaboration and controlled substance prescribing.^7,8

Psychiatrists bring the broadest pharmacological expertise, especially for complex or refractory cases. This includes patients with complex medical and/or psychiatric comorbidities and treatment-resistant cases. With psychiatrists comprising only 5% of the mental health workforce, focusing their advanced expertise on the most challenging cases makes sense.⁹

Although psychotherapy training remains a core component of residency for psychiatrists, managed care has increasingly pushed for 15-minute med checks and pharmacological interventions. Economic and systemic factors have largely influenced the shift. Psychiatrists can treat multiple medication follow-up cases in the time it takes to conduct 1 therapy session, and reimbursement incentivizes the use of other “less expensive” mental health professionals for therapy. As a result, by the mid-2010s, more than half of US psychiatrists were not providing psychotherapy to their patients, and only one-fifth of psychiatry patient visits included psychotherapy in 2016.¹⁰

Nevertheless, psychiatrists’ training in psychotherapy is extensive, relative to NPs and PAs. They also receive training in other psychiatric modalities (eg, neuromodulation). As a result, psychiatrists provide expertise in both the mental and physical aspects of treatment and can offer comprehensive psychiatric treatment.

Meanwhile, psychiatric mental health nurse practitioners (PMHNPs) often handle ongoing medication management for patients. Studies show that psychiatric NPs treat roughly comparable patient populations with similar prescriptions and services compared to psychiatrists.¹¹ The nursing ethos of communication and patient education means PMHNPs often naturally emphasize listening and coaching during appointments.⁶ However, similar to psychiatrists, psychiatric NPs currently have varying involvement in psychotherapy, and, in practice, many PMHNPs also find themselves focusing on medication visits rather than weekly therapy sessions, especially in high-volume clinics.

PAs in psychiatry likewise focus on pharmacological treatment. Physician assistants’/associates’ training leverages the medical model and its strong foundation in pathophysiology and the fundamentals of medicine. This provides an excellent base to build psychopharmacology expertise, making PAs well equipped to manage psychiatric prescribing.¹² Compared with their counterparts, PAs generally leverage psychotherapy the least of the 3 professions. Unless they pursue postgraduate psychotherapy training, psychiatric PAs typically do not have formal psychotherapy training. As a result, most PAs provide supportive listening and basic counseling in the context of medication appointments and will refer patients to psychologists, social workers, or therapists for structured therapy.

PAs often serve as primary behavioral health clinicians for patients, especially in team-based care. PAs are highly adept at collaborative care, working alongside psychiatrists, NPs, psychologists, social workers, and others in a multidisciplinary mental health team. For example, a PA may manage an inpatient psychiatry unit day-to-day, handling intakes, leading team meetings on patient care, and adjusting medications, with a psychiatrist overseeing the unit and available for consultation.¹³

With workforce shortages, increased demands for care, and health system requirements, modern behavioral health care often involves multidisciplinary teams, including 1 or more of the psychiatric prescriber professions as well as psychologists, counselors, social workers, psychiatric nurses, case managers, and peer support specialists. With their in-depth knowledge, psychiatrists frequently take leadership or consultative roles in teams. For example, in an integrated care model, a psychiatrist might supervise a caseload of patients managed day-to-day by a therapist or PA/NP, providing expert guidance on diagnostics and medication adjustments.

On the other hand, psychiatric NPs and PAs may serve as the primary psychiatric provider, especially in team settings that lack a full-time psychiatrist. In inpatient or emergency settings, PAs and NPs often complete initial evaluations and manage admissions, with psychiatrists on call for backup. In outpatient settings, PAs and NPs increase capacity, allowing more patients to be seen promptly.¹³

Exploring the Professions’ Educational Foundations

The psychiatrist’s educational pathway is the longest and most medically comprehensive, producing specialists with deep expertise in mental illness, pharmacotherapy, and the biological underpinnings of behavior, as well as training in psychotherapy and general medicine. Training is intensive, with thousands of hours of clinical experience and gradual responsibility for patient care following an extensive medical education. Following residency, psychiatrists may pursue fellowships in subspecialties such as child and adolescent psychiatry, addiction, geriatric, and forensic psychiatry, further extending their training.

As advanced practice registered nurses specialized in mental health care, PMHNPs are trained in the nursing model, which emphasizes holistic patient-centered care, psychosocial considerations, and health education to complement their clinical skills. PMHNP training generally involves either a master of science in nursing or a doctor of nursing practice with a specialization in psychiatric mental health.¹⁴ Unlike general NP tracks, psychiatric NP programs primarily focus on behavioral health.

Although the exact requirement for clinical training for PMHNPs varies, it involves at least 500 to 1000 hours of supervised clinical practicum in mental health settings, with 500 hours as the minimum for certification, and many programs requiring more. Notably, PMHNP certification requirements stipulate competence in at least 2 therapy modalities.¹⁴

In contrast, PAs are trained in a medical model similar to physicians but in an accelerated and focused format. PA education is generalist medical training at the master’s level, intended to prepare graduates to diagnose and treat illness. Programs involve didactic coursework in medical sciences (eg, anatomy, pharmacology, pathophysiology) and clinical rotations in major disciplines (eg, family medicine, internal medicine, surgery, pediatrics, psychiatry).¹⁴

Although there is no separate degree for psychiatric PAs, postgraduate psychiatry fellowships and doctorate programs have emerged to provide psychiatry-focused training.¹² Aside from those programs, PAs rely on physician mentorship and on-the-job learning.

By design, PAs practice in a team-based model, although the degree of required supervision varies from state to state. Many states are moving to a collaborative practice model, and some have eliminated the legal requirement for a specific supervisor. For example, South Dakota recently enacted legislation to remove the requirements for specific physician supervision after 6000 hours of clinical practice.¹³

Looking to the Future: Policy Recommendations

Given the projected shortages in the US behavioral health workforce, effectively leveraging all 3 prescribing professions is essential.¹⁵ In doing so, policymakers, health care leaders, and clinicians must aim to ensure that patients receive timely, high-quality mental health care by maximizing the individual and combined roles of psychiatrists, NPs, and PAs (Table 2).

TABLE 2. Future Workforce Recommendations

Modernizing the scope of practice laws is essential to fully leverage the capabilities of NPs and PAs in behavioral health care. For example, expanding full practice authority for psychiatric NPs across additional US states would allow NPs to assess, diagnose, and prescribe independently without mandated physician oversight.¹⁴ Similarly, PAs would benefit from updated regulations aligned with the Optimal Team Practice concept, allowing them to work collaboratively without a specific supervising physician agreement. Easing restrictions would increase workforce flexibility, reduce barriers to care in underserved areas, and enable timely psychiatric care.^14,15

Importantly, modernizing scope of practice laws does not equate to altering the clinical scope of PAs or NPs. Updates to state regulations should focus on preserving the principle that clinician roles should be determined by competence, experience, and the needs of their specific practice setting. Safeguards such as requiring certification in psychiatry and a period of supervision/mentorship for new graduates can ensure quality while increasing autonomy.

Policies and programs should support interprofessional collaboration. Funding and incentivizing team-based care models, such as the Collaborative Care Model (CoCM), can facilitate coordinated treatment across psychiatrists, NPs, PAs, therapists, and primary care providers.¹⁶ Establishing multidisciplinary behavioral health teams, particularly in high-need rural or underserved areas, would enable a more efficient division of labor and ensure patients receive comprehensive care. Formal mechanisms such as shared electronic health records, regular case conferencing, and telehealth consultations can support this collaborative approach. Payment models should reimburse collaborative efforts, including psychiatric consultations and care coordination activities, to reinforce team-based practices. For example, a payment policy reimbursing a psychiatrist for supervising an NP/PA or consulting on cases remotely would encourage greater collaboration.

In this way, integrated teams can handle a higher volume of patients: A psychiatrist can extend their expertise to many more patients by supervising NPs/PAs, and NPs/PAs benefit from physician mentorship on complex cases.¹²

Funding interdisciplinary training and team implementation leads to better communication and understanding of roles. The result is more comprehensive care: Medication, therapy, and social support work in concert, making providers more effective together rather than in isolation.

Investing in Education and Training Pathways for Clinicians

Strengthening education and training pipelines is necessary to ensure a competent and sustainable workforce. This includes increasing federal funding for psychiatry residency positions, building on the 20% expansion enacted between 2014 and 2019.¹⁴ Expanding psychiatry residencies is crucial, as psychiatrists handle the most complex cases and are needed as teachers/leaders for the other behavioral health professions. However, even with more residencies, psychiatrists alone won’t meet the demand.

Thus, investing in postgraduate training programs for PAs and NPs (eg, psychiatric fellowships and residencies) is essential. Loan repayments can be an efficient incentive to increase PA/NP entry into psychiatry. Academic partnerships between psychiatry departments and NP/PA programs can foster interprofessional mentorship. Joint clinical rotations and interprofessional simulation experiences would break down silos between professions and promote early collaboration.¹²

Investment is also needed in education infrastructure. Standardized curriculum requirements in graduate programs, especially for PA and NP programs that vary in psychiatric and psychotherapeutic didactics, will produce more uniformly prepared clinicians.

Optimizing Clinical Roles in Behavioral Care Delivery

Health care system efficiency and patient access can be increased if clinician roles are maximized. This should involve aligning responsibilities with the level of training and scope. Similarly, the health care system should look to telepsychiatry, which can further extend the reach of psychiatrists by enabling remote consultation and collaboration with NPs and PAs across multiple sites.

Top-of-license practice means each professional is performing tasks that require their level of training, thus avoiding underutilization (eg, a psychiatrist conducting simple medication checks), overextension (eg, an NP forced to manage a case beyond their comfort without support), and clinician burnout.

By structuring care so that NPs/PAs manage straightforward cases, systems can dramatically increase patient access to medication management without sacrificing quality. Psychiatrists then have more availability for consultations, oversight of complicated cases, or administration of specialized treatments, such as ECT or intricate therapy.⁶

Concluding Thoughts

Addressing the mental health needs of Americans will require the complementary contributions of psychiatrists, psychiatric NPs, and PAs. Each profession has different training paradigms that translate to unique strengths in practice. By understanding these differences, health care systems and policymakers can maximize their contributions, and policy changes can create a more cohesive and effective behavioral health workforce that emphasizes interprofessional collaboration.

Ultimately, the goal is to ensure that every patient seeking mental health care can access a qualified clinician in a reasonable time frame. This depends on ongoing partnerships between psychiatrists, NPs, and PAs; mutual respect for each role’s expertise; and supportive regulatory policies that allow professionals to practice to the full extent of their education and training. With these steps, the US can move toward a future in which team-based, multidisciplinary care is the standard, and the strengths of different providers are blended to meet the mental health needs of all communities.

Mr Asbach is a psychiatric PA and serves as the medical liaison to the American Psychiatric Association on behalf of the American Academy of Physician Associates. He is also a member of Psychiatric Times’ editorial board. Mr Anderson is a PA student at D’Youville University and a technical sergeant in the US Air Force, with a background in military medicine and a commitment to mental health advocacy. Ms Marin is a PA student at Daemen University. She is also a proud member of Daemen’s PA Student Society and is dedicated to mental health and advocacy.

References

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