US Psychiatric Resources: A Country in Crisis

Bret Stetka, MD

Disclosures

September 22, 2010

In This Article

Editor's Note:
The United States is facing a severe lack of psychiatric care resources. Given the current economic crisis, the problem is only getting worse as state budgets for mental health care continue to be cut. Medscape recently interviewed psychiatrists Dr. Joe Parks, Dr. Richard H. Weisler, and Dr. Henry A. Nasrallah on the magnitude, impact, and means of addressing this critical situation.

The Problem

Medscape: Evidence shows that this country is short 45,000 psychiatrists.[1] Dr. Parks, how severe is this shortage and will it only get worse, as epidemiologic data suggest?

Dr. Parks: All of the providers I talk to, whether they are at hospitals, community mental health centers, or primary care physician practice, complain that they can't get the psychiatric staffing they want. I think stigma clearly has something to do with it. We've talked about reducing the stigma associated with psychiatric disorders, and it really has dropped tremendously in the last 10 years. It used to be that patients would not admit they took an antidepressant; now they compare antipsychotics at cocktail parties. This reduction of stigma has released huge pent-up demand for psychiatric services and care.

Dr. Weisler: I also think that if you look at times of stress, like we have had in the last few years with the economy, then you can get increased psychiatric demand, particularly in terms of depression, anxiety, suicidality, and drug abuse.

Dr. Nasrallah: Beyond just reducing stigma, if you recall a report by the President's Mental Health Commission,[2] of which Dr. Michael Hogan -- at the time, the Ohio Director of Mental Health -- was chair, the document reported that the mental health system in the United States is broken.

That commission started its work a decade ago and clearly indicated that our seriously mentally ill patients are not well served for numerous reasons. Beyond just a lack of resources, the system is a problem unto itself.

Dr. Weisler: Let's talk about psychiatrics resources, first in terms of number of psychiatrists or mental health professionals needed. Like Joe was saying, there are a lot of vacancies; in fact, in many areas, psychiatry is the number-one area in which more professionals are needed.

Medscape: And it appears to only be getting worse, correct? According to the National Association of State Mental Health Program Directors (NASMHPD),[3] mental health spending dropped 5% from 2009 to 2010.

Dr. Weisler: Yes, and it is predicted to go down another 8% in 2011.[1]

Dr. Nasrallah: The problem started when people around the country, states especially, legislators, politicians, even the mental health professionals, thought, "Now that we have antipsychotic drugs that can treat serious mental illness, we can empty the hospitals." The system was pretty stable up to the 1950s and even early '60s when the mass closure of state hospitals began, with the promise that the funding for state institutions that took care of the seriously mentally ill would be transferred to the community and people would be taken care of. Well, that did not happen; these were unkept promises in practically all states. Communities got only a small fraction of whatever money was saved.

Dr. Parks: I disagree that we had a stable system with the state hospitals open. In the '50s and '60s, state hospitals had thousands of patients and would have 3 or 4 psychiatrists for 2000 or 3000 patients. I remember touring a closed state hospital in Illinois with buildings with hundreds of patients on 1 wing. So there certainly was a shortage of psychiatrists then.

Dr. Nasrallah: What year was that? You do not look that old. [laughter]

Dr. Parks: [jokingly] I toured the empty campus; I did not tour it when it was functional.

Dr. Weisler: When I was a resident at UNC Chapel Hill in the late 1970s, I had an outstanding professor, David Young, who was in his mid-70s I believe . Apparently when he first started at Dorothea Dix Hospital, he said that they had roughly 4000 patients. I remember him saying on his first day that they assigned him somewhere between 1500 and 2000 patients which he was supposed to help take care of. I believe that was in the 1950s.

Dr. Parks: So this was not a stable situation. I think there has always been more demand than resources in terms of psychiatric services for the severely mentally ill. Even back in the '40s and '50s, states would put up to a third of their budget into the mental health system and it was still not enough. For a long time, psychiatry has been used as an attempt to redress social economic needs, housing, criminality. In a sense our role has been to take care of the people that others can't tolerate or understand.

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