Jacob M. Appel, M.D., J.D.

A recent report from the National Council for Behavioral Health shed stark numerical light on the ongoing shortage of psychiatrists in the United States.   At present, 55% of American counties lack a psychiatrist and the average patient waits twenty-five days for an appointment (1).   According to the report, the current supply of psychiatrists is 6.4% lower than the medical need and that figure is projected to rise to 12% by 2025 (2).   So what is to be done?  The ideal solution would obviously be increasing the number of psychiatrists.  Unfortunately, this approach may also prove the least realistic as other specialties compete for medical school graduates and the lure of large urban centers draws those who do pursue psychiatric residencies away from the rural and heartland communities where the shortage stands most acute.  Increasingly, states have been turning to non-psychiatrists to fill the existing gap.

The most conservative approach to this problem is to rely upon primary care physicians to conduct basic screenings and prescribe medications.  These medically-trained professionals may not have completed psychiatric residencies, but they do have extensive knowledge of pathophysiology and pharmacology—making them unlikely to mistake an organic illness for a psychiatric one or to prescribe a dangerous cocktail of drugs.  In addition, internists are often already familiar with the patients from routine clinical care and so serve as a logical point-of-entry for treatment.  Estimates are that appointments with PCPs already constitute the majority of physician encounters for depression each year (3).  However, PCPs may not be particularly attuned to, or interested in, the mental health needs of their patients.  Moreover, many are already overburdened—and primary care faces most of the same disparities and manpower shortages as psychiatry.

Increasingly, states are turning to two alternative options to meet mental health demands.  The first—and likely the most controversial—involves permitting psychologists to prescribe psychiatric medications.  On April 4, 2017, Idaho became the fifth state to enact legislation permitting clinical psychologists to prescribe, joining New Mexico (2002), Louisiana (2014), Illinois (2014) and Iowa (2016).  All of these were states with particularly significant existing scarcities of psychiatric providers.  The Idaho statue, which is not atypical, requires an eligible psychologist to earn a master’s degree in clinical psychopharmacology, complete a supervised practicum and pass a national exam, after which he must be supervised by an MD for two years before he is permitted to prescribe independently (4).   (Whether physicians will agree to provide supervision, considering the strong opposition to these laws from much of the medical community, remains to be seen.)  Critics argue that these credentials do not provide sufficient medical training to allow psychologists to substitute for psychiatrists.

A number of other jurisdictions have increased opportunities for nurse practitioners and physicians assistants to provide psychiatric services.  Unlike psychologists, all NPs and PAs may generally prescribe; the question that arises is under what circumstances they may do so independently.  Twenty-two states—nearly all in New England or west of the Mississippi—now allow NPs, under certain circumstances, to practice independently of physicians (5).   Many also allow PAs to practice without onsite supervision.  Yet barriers to full autonomy remain in many jurisdictions.

In some regards, the conflict over who should prescribe is a classic “turf” war pitting MDs against other  professionals.  What makes this battle peculiar—and counterproductive—is that there is more than enough turf to go around—especially in poor and rural communities.  In large swaths of the country where there are no psychiatric providers at all, allowing psychologists and NPs to provide care will not compromise anybody’s health.  Rather than opposing the prescribing authority of psychologists and independent practice of NPs across the board, psychiatrists and their professional organizations would be wise to embrace such changes in those geographic areas that are chronically underserved.  One can argue whether a well-trained non-MD can offer as effective psychiatric care as an MD.  But surely a well-trained non-MD is preferable to no psychiatric care at all.

References

1. National report offers ways to address psychiatrist shortage, Business Record, Wednesday, March 29, 2017 available at http://www.businessrecord.com/Content/Default/-All-Latest-News/Article/National-report-offers-ways-to-address-psychiatrist-shortage/-3/248/77190
2. Stauffer, Heather “Report: Shortage of mental health care professionals, already severe, is likely to worsen,” Lancaster Online, March 31, 2017 available at http://lancasteronline.com/news/local/report-shortage-of-mental-health-care-professionals-already-severe-is/article_3fe14b42-1620-11e7-8690-874abbc86969.html
3. Luthra, Shefali, “For depression, primary care doctors could be a barrier to treatment,” Kaiser Health News, March 7, 2016 available at http://www.pbs.org/newshour/rundown/for-depression-primary-care-doctors-could-be-a-barrier-to-treatment/
4. Valentino, Tom. “Idaho to allow psychologists to prescribe medications,” Behavioral Health Executive, April 11, 2017.
5. https://www.aanp.org/legislation-regulation/state-legislation/state-practice-environment/66-legislation-regulation/state-practice-environment/1380-state-practice-by-type#new-york-open