About once a shift, I see a patient who has been unnecessarily — and often to his or her dismay — routed to my hospital’s locked psychiatric emergency unit in the process of simply trying to figure out where to go for routine psychiatric care. I’ve evaluated an attorney, a medical student, an internationally renowned musician, and many others who didn’t need to go through the unpleasant and potentially scary process of sitting through an extensive evaluation in an austere, security-monitored environment. Their journeys took them to this daunting unit not for lack of acumen or social or financial resources, but because finding the correct mental health care pathway can be bewildering and wrong turns are common.
Nonetheless, they’re among the fortunate minority who receive care. An estimated 40 million Americans experience mental illness in a given year. More than half of them do not, or cannot, get treatment.
For most Americans who seek treatment for issues like depression, anxiety, bipolar disorder, schizophrenia, and obsessive-compulsive disorder, navigating the way to mental health care is a challenging endeavor. Why? The dearth of providers, the uncoordinated panoply of practitioners with disparate and confusing titles and qualifications, and the costs of care have created a disorienting health care jungle where untreated mental illness is prevalent. It doesn’t have to be that way.
One of the biggest barriers to better mental health care is the lack of qualified providers. Some experts say we simply need to train more psychiatrists. That recommendation, often made by psychiatrists, is based on the idea that their medical background and specialized training are needed to improve mental health care.
Yet psychiatrists are the costliest care providers in the mental health care system. Just adding more of them to the current structure won’t fundamentally change the fact that care is expensive and confusing to access. And there isn’t solid evidence that psychiatrists alone provide better outcomes than other clinicians in treating many fundamental mental health issues like generalized anxiety and depression.
I believe we need three key innovations to improve the delivery of mental health care in the U.S.: shifting some tasks to physician extenders, integrating psychiatric care with primary care, and supplementing clinical capacity with software-based therapy tools.
Task shifting. Physician assistants (PAs) with specialized training in mental health could bolster the mental health workforce. Shifting the care of uncomplicated patients who require straightforward clinical decision-making to such PAs, working under the supervision of psychiatrists, could be a huge help where psychiatrists are few and their geographic distribution doesn’t match the need for them. Currently, there are too few psychiatric PAs to make a big difference — only 1.3 percent of the 125,000 certified PAs practicing in the U.S. work in psychiatry. Building more robust and well-structured PA training pathways in mental health would allow psychiatrists to spend more time working with people who have complex, unstructured clinical problems, which require greater expertise.
Integration with primary care. Another way to increase access to mental health care involves adding front-line practitioners and screening processes within primary care practices, the places where patients most often interact with the health care system. We can build capacity by having primary care doctors flag patients for further evaluation by psychiatric PAs and other mental health-focused physician extenders. These practitioners can screen more patients, implement straightforward first-line treatments, and maintain consultation and referral options to psychiatrists embedded in primary care offices. This structure, known as collaborative care, consistently demonstrates better mental health outcomes than standard management in primary care settings.
Technology-based tools. Novel technologies can help make care more efficient and expand the reach of practitioners. Using video conferencing to hold mental health “visits,” for example, can overcome some of the problems associated with the inequitable distribution of mental health practitioners. Software-based tools that deliver standard cognitive behavioral therapy have been shown to be as effective as in-person therapy. Although technology approaches are often oversold by early adopters as replacements for clinicians, and summarily dismissed by traditionalists, they have already demonstrated their value as a component of versatile and comprehensive mental health care.
Failing to expand access to mental health care comes with an enormous burden. First there is the corrosive effect of untreated mental illness on quality of life for millions of Americans. Then there is the cost — by one estimate, untreated mental illness costs the U.S. $225 billion a year, and that doesn’t include the cost of lost productivity. The University of Michigan’s Institute for Social Research once estimated that 217 million days of work are lost in the U.S. each year due to mental illness and substance abuse problems. That translates to as much as $50 billion in lost productivity each year.
Mental health care systems stand a better chance of meeting the needs of the 21st century not by just adding more psychiatrists, which would only augment how care has been provided in the past, but by fundamentally changing how care is provided. Psychiatrists will undoubtedly be essential for providing high-quality care, but they should do it mainly as clinical supervisors rather than as frontline workers. Well-trained physician extenders can reduce the cost of treating many cases of depression and anxiety.
Integrating mental health care in primary care settings represents the most effective way to seek out individuals in need of care and begin to address the disturbing fact that most people with mental illness don’t receive any care. Software-based video chat and therapy tools can help provide the new infrastructure to make care more efficient for all.
In the coming decades, the most valuable advance emerging from leaders in psychiatry and mental health care likely won’t be a breakthrough in drug development or neuroscience, or training more psychiatrists, but crafting sensible design decisions to create better mental health care systems.
Scott Breitinger, M.D., is a resident in psychiatry at NewYork-Presbyterian Hospital|Weill Cornell Medical College in New York City.
Many of these things are not medical issues. Bipolar disorder is created by the drugs used to treat depression – or ADHD. Depression can be caused by statins blood pressure, or contraceptive drugs. Trauma is always an issue – but upset is a rational (not “crazy, mad, or disordered”) response to trauma.
Even the DSM dismisses a diagnosis when “environmental circumstances” warrant it, and also when it is induced by drugs.
These are human conditions, not medical illnesses. Psychiatrists are part of the problem, not the solution. There are good ones – but much of the “diagnose and prescribe” model is making people worse, not better.
PA’s: well, if they are anything like Nurse Practitioners, this is not a solution. It’s corporate advantage, because they are cheaper than real doctors. But I was speaking to a GP who was telling me how, when she felt that she needed to refer someone to a specialist – they ended up seeing the PA of the specialist, and not the specialist. She felt that if she’d known that, she would’ve treated them herself, and that the treatment by the PA was inadequate for her referrals.
My personal experience with psych NP’s has been less than stellar. They just whipped out prescription pad and followed a chart. They had no idea about how negative were the effects of their prescriptions and drugs.
Tech tools – I hear they are good, especially mindfulness based applications. But many people are reluctant to share over apps and corporate applications, as privacy is not assured in these applications, and their condition might be shared inappropriately across corporate lines.
Primary care GP’s are under too much corporate pressure as well – to perform their analysis in the 12 minute slot.
The answer is presented in Robert Whitaker’s excellent “Anatomy of an Epidemic” when he hearkens back to a simpler time when the disturbed were offered places in homes – the Quakers had an initiative – and just fed and kept comfortable, and listened to – by LAYPEOPLE – and they got better and went back to work and society when they resolved their crisis.
Dr. Breitinger,
I noticed that your article (conveniently?) made no mention of nurse practitioners (NPs) in bridging the patient care access gap, as you only wrote about using physician assistants (PAs).
Please do your research. Board-certified psychiatric mental health nurse practitioners (PMHNP-BC) are an integral part of the solution to increasing patients’ access to quality, cost-effective, culturally-sensitive mental healthcare.
Oh and another thing. Please do NOT refer to either PAs or NPs as “Physician Extenders”, a derogatory (disrespectful) term coined by physicians. NPs and PAs are Non-Physician Clinicians and allied with physicians in effectively responding to the surge in patient demand for (mental and other) healthcare services.
Thanks,
Ruth (a PMHNP-BC)
I disagree completely that PA’s are the answer to this problem! PA’s have a limited education and just getting experience does not give them the ability to practice in this specialty! You need PMHNP-BC are advanced practice nurses who have years of practice in this field (residency) and evidence based knowledge to assess, diagnose, treat with both prescribed medication and psychotherapy! They are the answer not someone that has two years of medical knowledge period! They have less then an RN-BSN! Please stop adding people that do not have the knowledge to address this problem!