Trends in the Treatment of Psychiatric Illnesses

A study published in the journal Health Affairs by Tara Bishop and colleagues confirms trends in the size of the psychiatric workforce that were predicted over a decade ago.

Between 2003 and 2013, the number of psychiatrists per 100,000 adults decreased by about 10% whereas the number of neurologists per 100,000 increased more than 15%. During this same time interval, the number of primary care physicians per 100,000 remained relatively stable. Although there has been an increase in the number of neurologists, there are still far more psychiatrists than neurologists (37,889 vs. 17,268 in 2013).

The number of medical school graduates entering the field of psychiatry has been gradually increasing over the last 15 years, however, this increase does not compensate for the larger number of psychiatrists who are retiring. During and after World War II, a large number of physicians became psychiatrists and these physicians have reached retirement age.

There is also an unequal distribution of psychiatrists around the U.S. Many more psychiatrists per 100,000 adults practice in large cities such as New York, Boston, Chicago, and Washington DC than in rural areas or in cities with smaller and less affluent populations.

In comparison to other specialties, a larger proportion of psychiatrists do not accept insurance, i.e., their patients pay out-of-pocket. (In a paper published in 2014, Bishop and her colleagues reported that 55% of office-based psychiatrists accepted private non-capitated insurance while 89% of office-based physicians in other specialties did. The discrepancy was similar for those accepting Medicare.) While psychiatrists’ incomes are at the lower end of physician incomes, they earn more money by treating patients who have the resources to pay non-discounted out-of-pocket fees. In larger urban areas, there is a ready population of individuals willing to pay for such out-of-pocket care. This limits the availability of psychiatrists to care for other patients, including those with insurance.

Recently, increased attention has been directed to the importance of recognizing psychiatric symptoms in patients seen by primary care physicians. Depression, anxiety disorders, and substance use disorders are all common and have major influences on the health of individuals. Treatment of most psychiatric disorders is now covered by insurance, but primary care physicians are finding it difficult to locate psychiatrists who accept new patients.

The ability to provide appropriate care for the more severely ill is further complicated by the substantial shortage of psychiatric inpatient beds. In another article in the journal Health Affairs, Jane Zhu and colleagues report on the length of time that patients with psychiatric disorders spend in emergency rooms in comparison to non-psychiatrically ill patients. Because of a shortage of psychiatric beds, psychiatrically ill patients often stay in the emergency room for long periods of time (which, on occasion, can be a day or more) waiting for a bed to become available or for transfer to another hospital where a bed can be located. This leads to emergency rooms crowded with psychiatrically ill patients waiting to be hospitalized, often involuntarily.

One reason for the psychiatric bed shortage is that hospitals are not reimbursed as much for the care of psychiatric patients as they are for patients requiring medical or surgical care. Therefore, many hospitals have decreased or eliminated psychiatric beds. Furthermore, because of tightening state budgets, psychiatric beds in state hospitals have diminished and some states have gotten out of the business of providing acute inpatient psychiatric care. Finding a longer-term bed in a state facility is also extraordinarily difficult.

What can be done to help patients receive psychiatric care when they need it? Integrative care models are on the increase. In these models, primary care teams utilize non-physician mental health professionals who communicate with psychiatrists. Psychiatrists are involved in consultative and didactic roles. Patients who are very ill or do not respond to treatment are seen one-on-one by psychiatrists. In order for integrative care models to be successful, new systems of reimbursement must be developed that would encourage psychiatrists to accept insurance. Also, psychiatry residency training programs should encourage collaborative care models by providing such experiences to their trainees.

An increase in the number of beds dedicated to psychiatrically ill persons is also urgently needed. This will require the development of financial solutions at both state and federal levels. In the long run, such solutions will save money when one considers the societal costs associated with recurring short-term psychiatric admissions to high-cost general hospitals, complications in treating co-morbid medical illnesses, disability resulting from psychiatric illnesses, and the impact of untreated mental illness on crime and homelessness.

Finally, it is essential to continue attracting talented medical students into the field of psychiatry. Increased recognition of the public health issues associated with untreated psychiatric illnesses together with exciting research advances in the field have caught the attention of bright students interested in serving the very sick and participating in new discoveries. Unfortunately, increasing the numbers of students entering the field is a longer-term, rather than shorter-term, solution to the shortage of psychiatrists since an increasing number of trainees today will not translate into substantial increases in the total workforce of psychiatrists for a decade or more.

Psychiatry Essential Reads

The Outsourcing of Mental Healthcare to the Public Sector

Empath Units: A New Approach to Psychiatric Emergency Care

This post was written by Eugene Rubin MD, PhD, and Charles Zorumski MD.