Psychiatric Care in the US: Are We Facing a Crisis?

Psychiatric Times, Vol 39, Issue 4,

What US state has the best mental health care?

By the end of 2021, many American adults found themselves in
the worst mental state in years. According to the US Census Bureau’s Household Pulse Survey, 47% of adults reported symptoms of anxiety,1 39% reported symptoms of depression,1 and 1 in 5 adults disclosed suffering from a mental illness.2 Despite this, it is estimated that less than half of Americans with a mental disorder get adequate treatment.3

“It has been just over a year now since the COVID-19 pandemic struck the United States full force. A year of hunkering down and Zooming in, teleworking and telepsychiatry, economic and social upheaval, and steady scientific progress. Looking back to last March, we knew this would be difficult. But we didn’t know how difficult. And we certainly didn’t know that the challenge of COVID-19 would last this long,” said Joshua A. Gordon, MD, PhD, director of the National Institute of Mental Health, in a 2021 director’s message.4

Between physician burnout, an aging workforce, bureaucratic and insurance demands, and poor compensation, how is the country doing when it comes to providing psychiatric care? In this detailed look at psychiatric care in the US, learn what states are best providing care for their residents, why we are experiencing this crisis in accessing mental health services, and what is being done to stem this wave.

State By State

In a recent study, investigators sought to understand which states are the best at tending to the psychiatric needs of their residents by comparing all 50 states and Washington, DC, to determine how they ranked across 3 categories: cost, access, and quality.5

According to their findings5:

The best state overall for mental health care is Maryland, and the worst is Mississippi.

Massachusetts has the fewest uninsured inhabitants, whereas Texas has the most uninsured inhabitants.

Vermont has the most mental health providers per capita, and South Carolina has the least.

Utah has the highest rate of suicidal thoughts, and New Jersey has the lowest.

Ainsley Burke, PhD, assistant professor of clinical psychology at Columbia University, believes there is a reason behind these rankings. “More liberal states are doing a better job with mental health care than conservative states,” she said. “Mental health is more openly discussed in open-minded communities with less judgment. Conservative laws and mandates, for example banning discussion of certain topics like sexual identity in schools, discourages people from talking about issues and seeking treatment.”5

Cannot Afford Care

According to data from the 2021 Commonwealth Fund International Health Policy Survey, conducted among adults 65 years and older, US seniors are more likely than their counterparts in other nations to have received a mental health diagnosis.6,7 Approximately 1 in 5 adults aged 65 or older in the US has a diagnosed mental health condition, whereas in the countries with the second-highest rates of mental health diagnoses—New Zealand, Canada, and France—only 13% of adults older than 65 years have received such a diagnosis. Other countries, such as Germany, have as few as 5% of adults older than 65 years reporting a mental health diagnosis.7

Despite this high rate, older adults in the US are also significantly more likely to have to forego mental health care because they cannot afford it. Approximately 26% of US adults older than 65 years who were surveyed said they did not access needed mental health care because of costly patient financial responsibility.6,7 Why? Lapses in health payer coverage for mental health services may be to blame.

“At the end of the day, you know, these benefits should be covered,” said US Secretary of Labor Martin J. Walsh.8

For example, an individual with major depression can spend an average of $10,836 a year on health costs versus an individual without major depression who has an average annual health care cost of $4584.9 Paying more than $10,000 out of pocket annually when the median household income in 2020 was $67,521 simply is not feasible for some families.10

The Kids Are Not Alright

US youth are facing a crisis of their own. Prepandemic, approximately 1 in 6 US children aged 6 to 17 had been diagnosed with a treatable mental health disorder, and the additional stress of the COVID-19 crisis has resulted in a surge of anxiety and depression in children and adolescents. Despite this marked increase, mental health services sharply declined among individuals 18 years and younger. Although telehealth has helped connect youth to clinicians, data have shown that many are still not getting the care they need.11

To support struggling children and adolescents, the Centers for Disease Control and Prevention (CDC) highlighted 3 areas—innovative solutions, workforce gaps, and rural community challenges—as a focus to improve access to mental health care for children (Table).12

“The state of child and adolescent mental health in America reflects 2 overlapping pandemics, a mental health pandemic existing before and worsened by the COVID-19 pandemic. It is an acute and chronic situation, where we already had a silent pandemic of children not being able to receive the mental health care that they need and deserve. The pandemic has only worsened that,” Warren Y.K. Ng, MD, MPH, president of the American Academy of Child and Adolescent Psychiatry, told Psychiatric Times™. “It has really exposed many of the inequities and disparities that existed beforehand, exacerbating the experiences particularly of the racial and ethnic minoritized youth who are disproportionately impacted from all social determinants of care.”

The silver lining—if there can be one—to this disastrous situation is the opportunity to talk about mental health, according to Ng. In order to best care for children and teens right now, Ng recommends (1) being mindful of health equity, diversity, and inclusion, (2) taking the time to listen and involve our youth, (3) advocating for more mental health services and a sustainable mental health delivery system for young people, and (4) being creative in treatment and care approaches to envision a better future for kids.

Physician Shortage

To provide quality, affordable care, we need rested and ready physicians—and, unfortunately, the US is running low. Research shows that the US is likely to continue experiencing a shortage of psychiatrists and other mental health professionals for at least another 3 years.13

Already, two-thirds of all primary care providers in the US say they have trouble finding mental health specialists to whom they can refer their patients. Approximately 55% of continental US counties have no psychiatrists, and 77% report a severe shortage.14

In some states, such as Maine, psychiatrist shortages have reached crisis levels, where the number of psychiatrists dropped by 50% between 2015 and 2020.15 This means patients could spend up to a year and a half waiting to see a clinician.

Contributing to this problem is the retirement rate, with experts predicting a mass exodus. Approximately 70% of practicing psychiatrists are 50 years or older and are quickly approaching retirement. Without an influx of psychiatry students, the demand for psychiatrists will outstrip supply by 25% in 2025.14

“Fortunately, the number of medical students applying for psychiatry residency in the US and Canada has been increasing in recent years, due in part to the better quality of life perceived with the practice of psychiatry versus other medical specialties and the recognition by young physicians that mental health and addictions care [is] important, especially in light of the impact of the COVID-19 pandemic,” Tony P. George, MD, told Psychiatric Times™. George is a professor of psychiatry at the University of Toronto, an editorial board member of Psychiatric Times™, and incoming coprincipal editor of the journal Neuropsychopharmacology.

This shortage has led to an increased reliance on physician assistants and nurse practitioners. According to the US Bureau of Labor Statistics, the employment of nurse practitioners is expected to grow by 52% from 2020 to 2030.16

“In the context of our current untenable access to and delivery of mental health services in the United States, psychiatrists need to embrace, support, and collaborate with psychiatric-mental health nurse practitioners (PMHNPs), who already provide a significant percentage of psychiatric treatment here. Upon graduating medical school, we took an oath to ‘do no harm,’ which includes expanding psychiatric providers to provide access of quality treatment to all,” said John J. Miller, MD, editor in chief of Psychiatric Times™.

Sara Robinson, MSN, RN, PMHNP-BC, could not agree more. “In states where nurse practitioners have independent practice authority, PMHNPs are able to provide significantly more mental health services [versus] states limiting nurse practitioner practice,”17 she said. “…The training and background of a PMHNP differs from that of our psychiatrist and psychologist colleagues, but by utilizing our strengths and area of expertise, the work is quite complementary.

“Ultimately, when we are all working together to expand the well-trained mental health workforce and meeting patient needs, we are facilitating improved outcomes for patients and creating a more positive clinical environment for current and future providers. The need for mental health care well exceeds the providers available in the country. The ‘great resignation’ is impacting our health care providers and mental health care providers, too. Demonstrating teamwork and collaboration will help to draw more young and motivated individuals into this meaningful work.”

Moving Forward

Several pieces of legislation aim to help put out the fire on this crisis. In Wisconsin, Representative Paul Tittl and Senator Kathy Bernier have introduced Assembly Bill 267, which creates a tax incentive for psychiatrists graduating from medical school who stay in Wisconsin to practice psychiatry.18

“Attracting psychiatrists to our state and addressing these situations today is better than leaving them for our children and grandchildren to handle when the problems have grown even larger,” said Tittl.19

In Iowa, Representative Ann Meyer and other lawmakers introduced 4 proposals to support mental health care workers and increase access to psychiatric treatment19:

House Study Bill 532 would create a new residency program through the University of Iowa, and support 12 students each year working at the state’s mental health facilities in Independence and Cherokee or at the Iowa Medical and Classification Center.

House Study Bill 537 would help mental health practitioners who agree to work in Iowa for at least 5 years by appropriating $1 million for loan forgiveness programs.

House Study Bill 530 would require the Iowa Department of Human Services to create a Medicaid rate for patients who need higher levels of mental health care.

House Study Bill 531 would increase capacity by 50% at the state’s 2 mental health institutes by adding 32 adult beds and 14 adolescent beds.

Meanwhile, the US Department of Labor, US Department of Health & Human Services (HHS), and US Department of the Treasury recently issued their 2022 report to Congress on the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, which found that health insurance issuers are failing to deliver parity for mental health and substance-use disorder benefits to the individuals they cover.20

“Access to mental and behavioral health support is critical as the COVID-19 pandemic continues to impact so many lives across the country,” said Xavier Becerra, secretary of HHS. “Unfortunately, as today’s report shows, health plans and insurance companies are falling short of providing access to the treatment many working families need. We are committed to working with our federal partners to change this and hold health plans and insurance companies accountable for delivering more comprehensive care.”

With clinicians stretched thin and pockets tight, it is imperative—now more than ever—to ensure Americans are receiving adequate and affordable mental health care.

“The current crisis in access to mental health services can be summed up with 1 word: more,” Miller commented. “During the past 2 years, exacerbated by the COVID-19 pandemic, there are more individuals suffering from depression, anxiety, substance abuse, social isolation, and interpersonal conflicts. There are more deaths by accidental drug overdose than ever before in our history. More and more people every day cannot access the mental health treatment they so desperately want due to long waits for an evaluation, lack of resources, and an underfunded mental health infrastructure. We need more psychiatrists, more PMHNPs, more psychotherapists, more mental health clinics, more psychiatric hospital beds, more partial hospitalization programs, more resources for the homeless suffering from mental illness, and more reforms to release individuals with serious mental illnesses from incarceration due to minor offenses, often directly related to the consequences of lack of treatment.”

“The mental health impacts of COVID-19 continue,” Gordon cautioned. “From all that we know, it is clear these impacts will outlive the pandemic itself. Therefore, it is crucial that we work together to apply evidence-based strategies to support the mental health needs of all Americans and to make these strategies broadly available, especially in vulnerable communities.”4

References

1. Week 40 Household Pulse Survey: December 1 - December 13. United States Census Bureau. December 22, 2021. Accessed January 25, 2022. https://www.census.gov/data/tables/2021/demo/hhp/hhp40.html

2. Mental health by the numbers. National Alliance on Mental Illness. Updated February 2022. Accessed March 2, 2022. https://www.nami.org/mhstats

3. New state rankings shines light on mental health crisis, show differences in blue, red states. News release. Mental Health America. October 18, 2016. Accessed January 25, 2022. https://www.mhanational.org/new-state-rankings-shines-light-mental-health-crisis-show-differences-blue-red-states

4. Gordon J. One year in: COVID-19 and mental health. National Institute of Mental Health. April 9, 2021. Accessed February 23, 2022. https://www.nimh.nih.gov/about/director/messages/2021/one-year-in-covid-19-and-mental-health

5. Horan S. Best and worst states for mental healthcare. HealthCare Insider. Updated January 27, 2022. Accessed March 2, 2022. https://healthcareinsider.com/best-states-for-mental-healthcare-346733

6. Doty MM, Shah A, Fields K, et al. Comparing nations on timeliness and coordination of health care. The Commonwealth Fund. October 4, 2021. Accessed January 25, 2022. https://www.commonwealthfund.org/publications/surveys/2021/oct/comparing-nations-timeliness-and-coordination-health-care

7. Heath S. US mental healthcare access trails other nations’ due to cost. Patient Engagement Hit. January 24, 2022. Accessed January 25, 2022. https://patientengagementhit.com/news/us-mental-healthcare-access-trails-other-nations-due-to-cost

8. Brancaccio D, Garretson M, Conlon R. Labor Department outlines unlawful imbalance in coverage between mental, physical care services. Marketplace. January 25, 2022. Accessed January 25, 2022. https://www.marketplace.org/2022/01/25/labor-department-outlines-unlawful-imbalance-in-coverage-between-mental-physical-care-services/

9. Lerner D, Lyson M, Sandberg E, Rogers WH. The high cost of mental disorders: facts for business leaders. Tufts Medical Center and One Mind At Work. Accessed January 25, 2022. https://secureservercdn.net/198.71.233.213/e47.77e.myftpupload.com/wp-content/uploads/2020/09/OMaW_Tufts-Study_High-Cost-of-Mental-Disorders-1.pdf

10. Shrider EA, Kollar M, Chen F, Semega J. Income and poverty in the United States: 2020. United States Census Bureau. September 14, 2021. Accessed March 2, 2022. https://www.census.gov/library/publications/2021/demo/p60-273.html

11. Mental health. InsureKidsNow. Accessed February 10, 2022. https://www.insurekidsnow.gov/initiatives/mental-health/index.html

12. Improving access to children’s mental health care. CDC. Updated December 2, 2021. Accessed February 10, 2022. https://www.cdc.gov/childrensmentalhealth/access.html

13. US Department of Health and Human Services; Health Resources and Services; Bureau of Health Workforce; National Center for Health Workforce Analysis. National projections of supply and demand for selected behavioral health practitioners: 2013-2025. November 2016. Accessed January 25, 2022. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/behavioral-health-2013-2025.pdf

14. Fact sheet: how primary care providers can help solve our psychiatrist shortage. Steinberg Institute. August 22, 2017. Accessed January 26, 2022. https://steinberginstitute.org/press-release/fact-sheet-primary-care-providers-can-help-solve-psychiatrist-shortage/

15. Leigh V. Shortage of psychiatrists in Maine near ‘crisis levels.’ News Center Maine. June 11, 2021. Accessed January 25, 2022. https://www.newscentermaine.com/article/news/health/mental-health/shortage-of-psychiatrists-in-maine-near-crisis-levels/97-adc291de-360e-4d0d-b8eb-207f94ad4342

16. Nurse anesthetists, nurse midwives, and nurse practitioners. US Bureau of Labor Statistics. Updated December 7, 2021. Accessed March 2, 2022. https://www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nurse-practitioners.htm#tab-6

17. Yang BK, Trinkoff AM, Zito JM, et al. Nurse practitioner independent practice authority and mental health service delivery in U.S. community health centers. Psychiatr Serv. 2017;68(10):1032-1038.

18. Brahm R. Local assemblyman aims to fix the psychiatrist shortage in Wisconsin. Seehafer News. January 20, 2022. Accessed January 25, 2022. https://www.seehafernews.com/2022/01/20/local-assemblyman-aims-to-fix-the-psychiatrist-shortage-in-wisconsin/

19. Akin K. Bipartisan bills would create 46 mental health beds, increase psychiatric residencies. Times-Republican. January 19, 2022. Accessed January 25, 2022. https://www.timesrepublican.com/news/todays-news/2022/01/bipartisan-bills-would-create-46-mental-health-beds-increase-psychiatric-residencies/

20. US Departments of Labor, Health and Human Services, Treasury issue 2022 Mental Health Parity and Addiction Equity Act Report to Congress. News release. US Department of Labor. January 25, 2022. Accessed January 25, 2022. https://www.dol.gov/newsroom/releases/ebsa/ebsa20220125