Too Few Psychiatrists for Too Many

April 16, 2015

In his Editorial, Dr Allan Tasman reflects on a recent meeting he attended in Asia and considers the implications for psychiatric service planning in the US.

From the Editor
Allan Tasman, MD | Editor in Chief

[[{"type":"media","view_mode":"media_crop","fid":"26691","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_8715143842632","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2517","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"width: 100px; height: 141px; float: right;","title":" ","typeof":"foaf:Image"}}]]Last month I attended the World Congress of Asian Psychiatry in Japan. I want to give you a brief report on some important issues that were raised that have pertinence for us in the US. This meeting was attended by psychiatrists from the 21 countries of the sponsoring organization, the Asian Federation of Psychiatric Associations (AFPA). There was an incredible diversity of cultures and economies represented, factors that have had great influence on the array and availability of psychiatric services across Asia.

While many statistics could be quoted, one that can easily serve as a proxy for the availability of psychiatric care is the number of psychiatrists available across the region. The World Health Organization (WHO) does periodic surveys of a wide range of service, health, and disease indicators, including the number of psychiatrists per 100,000 population. As many of you know, the US has the highest number of psychiatrists per capita in the world, about 16 per 100,000. Data from the WHO show that, by comparison, the South East Asia Region has .2 and the Western pacific Region has .32. These two WHO regions encompass all the countries of Asia and Australasia.

To put these numbers into perspective, Europe has about 10 psychiatrists per 100,000. Furthermore, geographic maldistribution adds to the difficulties with access to care. In China, for example, about 80% of psychiatrists are in urban areas, while about 80% of the population still lives in the countryside.

Knowing that developed nations such as Japan, Korea, Australia, and New Zealand have much higher numbers of psychiatrists, the lack of available care in countries with far fewer psychiatrists becomes even more apparent. Cambodia, for example, has about 50 psychiatrists for 10 million people, Bangladesh has 200 for 150 million, India has about 3500 for over a billion, and China about 10,000 for over a billion. The US, with only about 5% of the earth’s population, has about 30% of the world’s psychiatrists. Knowing how unavailable psychiatric care is for much of our own population gives even more clarity to the magnitude of the mental health care gap across most of Asia. Even in Japan, according to a prominent university chair of psychiatry, the average psychiatrist spends only 5 to 10 minutes for an outpatient visit.

In a plenary lecture at the meeting, Professor Pichet Udomratn from Thailand, the outgoing president of the AFPA, identified what he called demographic “megatrends” that will be major factors affecting demand for psychiatric services in the coming decades. These include an aging population, urbanization, increasing numbers of survivors of natural disasters, and increasing use of digital technology. All these echo the issues we have in the US.

In 1950, Asia had 44% of the world’s elderly population, but by 2050 the number will be 62%. Today, Asia accounts for about half the world’s cases of dementia. The increasing demand for not only medical and psychiatric care for these individuals, but for social services as well is a problem for which no solution has yet been developed. Moreover, while traditionally many families cared for their own aging members, the increasing urbanization of the population, with increasing intergenerational geographic dispersion already occurring, makes this a less likely care option.

At present 53% of the world’s urban population lives in Asia, where 16 of the 28 global “megacities” are located. We are all aware that urban crowding by itself is a risk factor for psychiatric problems. But, when this is compounded by accelerating urban migration of younger generations together with the increasing presence of international migrant workers, the risks are magnified substantially. The reliance on widespread use of electronic, rather than in person, family contact adds to the isolation of elderly family members who may not be living with or near the younger generation of, now absent, caregivers.

Professor Udomratn emphasized that much of Asia is a geologically very active area. That fact, paired with effects of climate change, he asserted, means that increasing attention to the mental health sequelae of natural disasters is of critical importance when developing the mental health system of the future. He said that from a public health perspective of mental illness, depression, PTSD, autism spectrum disorder, dementia, delirium, and all types of addictions should receive special attention in Asia in addition to the usual attention to all other significant disorders. On the basis of an increasing body of research, he believes that Internet addiction is a real illness that currently has significant impact in Asia, and which will be an increasing cause of morbidity in the coming years.

In other presentations, the impact of comorbid physical and mental disorders was mentioned. We know that comorbidity is likely to be an increasing problem globally because of a number of factors. First, demographic changes of the population mean that with longer life expectancy, there will be more significant physical illnesses. These will also intersect with depression and dementia, both of which are more common in the elderly. Furthermore, with ongoing medical advances, a greater number of people with severe illnesses will live longer. Finally, the growing environmental degradation will increase the incidence of severe illnesses, such as is already occurring with pulmonary and infectious diseases.

It’s no surprise that all the issues I’ve noted present a cautionary picture for the state of psychiatric service planning in the US. The first wave of baby boomers is nearing age 70, and we already know that we have a severe, and likely not remediable, shortage of qualified geriatricians and geriatric psychiatrists. In spite of the stated goal of integrated collaborative physical and mental health care embodied in the Affordable Care Act, there has been only minimal progress in health systems change in this regard. Perhaps if the court challenges to the law ever end, leaders of large health care organizations may feel the investment in such change is a good one. And we already know that we have a major geographic maldistribution in the US of all medical specialists, especially psychiatrists. As yet, no one has found a viable solution to this problem.

There was a great deal of other important work reported by our colleagues from Asia last month, but those issues will wait for future columns. For now, we need to consider how the trends is Asia mirror those here at home. I’m hoping we use our knowledge about what’s happening in Asia to generate greater interest in building more robust mental health systems abroad, which are not just needed in developing countries but here at home as well.


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