Considering a Career in Public Mental Health?

What a career in public mental health looks like—and how to get there.

Posted Nov 26, 2019

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Considering hitting the books? Jobs in public mental health come in all shapes and sizes.
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It's now late fall—the leaves have gone from bright colors to crunchy brown, Thanksgiving is just around the corner, many parts of the US have experienced snowfall, and stores of all kinds are pushing out their end-of-year sales.

But as a professor, there is another set of seasonal cues that this time of year brings: the time of submitting letters of recommendation for students and trainees, past and present, to support them in the next steps of their careers. Some of these students are applying to become clinicians of one sort of another, some want to pursue research degrees, and some want to answer the siren song of law school. Their future jobs may be in government, the nonprofit sector, research, or private business, but they are united by a common theme: all of these students are trying to become part of the multi-sector public mental health workforce.

What does a career in public mental health look like, and what kind of training paths get you there?

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Studying is hard work - good boy!
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While there is clearly more nuance than what I can describe here, I would say there are three major career paths in public mental health: 1) data and research 2) health services, social programs, and policy 3) direct clinical care. These each are a function of related, but distinct, paths of preparation. All reflect the fact that preserving, measuring, and promoting public mental health is largely a function of factors outside the traditional healthcare system.

1. Data and research: The Masters of Public Health (MPH) degree often is the first step in a career involving data collection or analysis related to mental health. All accredited MPH programs must address “core competencies” which range from statistical methods to health policy to leadership. It is a professional degree that has an internship and a culminating (generally research-based) project. Most schools offer MPH degrees in specialized areas (e.g., epidemiology, health behavior), which differ in emphasis rather than intent (e.g., MPH programs in health behavior tend to focus on program evaluation and implementation, whereas those in epidemiology tend to focus on quantitative data analysis and statistical methods). 

An MPH degree opens the door to many different types of jobs related to public health research and training. These include working directly with data (often quantitative, but increasingly a mix of quantitative and qualitative) as part of academic or industry research or health care quality assurance activities; directing or coordinating public health programs for local, state or federal agents; helping to draft or implement policies or programs to support mental health services; or leading nonprofits related to public health advocacy or services.

It is common for clinicians (e.g., MDs, RNs, PharmD’s) to earn an MPH either along with their clinical training through dual-degree programs or as a means to increase their research and program evaluation skillset. Finally, if you want to direct a research program on mental health, whether at a university or in the private sector, an MPH is often a necessary step in the process of earning your doctorate degree in any discipline of public health.

2. Health services, social programs, and policy: By far, the primary payer of mental health services in the United States is Medicaid. As such, having a good sense of the needs of the Medicaid population, the types of services that can be covered by this program, and the political sentiment about it is crucial to a successful career in public mental health services (often called behavioral health).

MPH programs will generally not provide the level of training needed about this care system that is needed. Instead, for people interested in designing and improving mental health care systems, I recommend either Masters of Social Work (MSW), with an emphasis on macro/policy, Masters of Public Administration (MPA), or a Masters of Public Policy (MPP) degree. All of these are professional degrees that require internship placements outside of academic research settings and thus provide a great deal of hands-on learning of “how the sausage is made” when it comes to behavioral health services.

These programs rightfully place emphasis on the social, economic, and political facets of public mental health. They may work in state or federal government, but often not in departments of public health. Instead, they may be in departments of social services, criminal justice, housing, employment, and other sectors that intersect with Medicaid programs in meaningful ways.

3. Direct clinical care: The vast majority of mental health care in the US is provided by non-mental health specialists. That is, if someone interacts with the healthcare system about a mental health need, it is almost always solely a general practitioner. There are often long wait times, and insufficient insurance coverage, for specialty mental health care. That being said, there is a wide array of healthcare providers, from social workers to nurses to psychiatrists, who participate in direct clinical care of persons with mental disorders. There is also a whole range of complementary providers, ranging from practitioners of acupuncture and yoga to employee assistance programs to informal peer support groups (e.g., NAMI), that support public mental health. 

This is likely an unpopular opinion, but when a student comes to me for career advice and tells me they are considering becoming a psychiatrist, I generally advise them to consider another path. This is for several reasons: First, less than half of psychiatrists currently accept Medicaid, which means that this type of care provider is out of reach for the majority of people with serious mental illness. There are market forces at play here, but even private insurance does not mean ready access to specialty mental health care. Plus, less than a third of office visits to psychiatrists are for psychotherapy; psychiatry, as practiced in the US today, is characterized primarily by medication management.

Instead, if students want to do therapy (which is generally the element of care that they find attractive about psychiatry), I encourage them to consider a degree in clinical social work, psychiatric nursing, or clinical psychology. I very much believe that people should access effective mental health care when they need it, but the reality is that psychiatry is not the primary provider of mental health care in the US anymore (if it ever was) and moreover, it has relatively little to offer in terms of prevention of mental disorders, particularly at the population level. As articulated by a recent article in the New England Journal of Medicine, the gap between population-level thinking about mental health prevention and promotion and psychiatry as a medical discipline is a long-standing one. 

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There's no time like (but) the present.
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There is a tagline in our field, "This is public health," that is intended to illustrate the myriad of activities, places, programs, and people that support public health. This is also true of public mental health. So as you head into the holiday weekend and your relatives inquire as to what your “plans” are, I hope you will consider the myriad ways to become a member of the public mental health workforce.

References

Beck AJ, Coronado F, Boulton ML, Merrill, JA. The public health workforce taxonomy: Revisions and recommendations for implementation. Journal of Public Health Management and Practice, 2018. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5932291/

Mojtabai R and Olfson M. National trends in psychotherapy by office-based psychiatrists. JAMA Psychiatry 2008. Available at: https://jamanetwork.com/journals/jamapsychiatry/article-abstract/210114

Gardner C and Kleinman A. Medicine and the Mind: The consequences of psychiatry’s identity crisis. New England Journal of Medicine 2019. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31665576

Kaiser Family Foundation. Facilitating Access to Mental Health Services: A Look at Medicaid, Private Insurance, and the Uninsured. 2017. Available at: https://www.kff.org/medicaid/fact-sheet/facilitating-access-to-mental-health-services-a-look-at-medicaid-private-insurance-and-the-uninsured/