In a not so surprising but still distressing article in Health Affairs, Jul 2016, Vol. 35, No. 7, pp. 1271-1277 entitled: “Population Of US Practicing Psychiatrists Declined, 2003–13, Which May Help Explain Poor Access To Mental Health Care,” discussed the long-standing decrease in the population of psychiatrists in the USA. This has been one of those long predicted results of issues that started in the 1980’s that were decried by legions of psychiatrists at all levels of psychiatric “guild” organizations from the American Psychiatric Association to the Amercian Academy of Psychiatrists, the Academy of Child and Adolescent Psychiatry and others. This all fell on deaf ears and in the Reagan era of deregulation, and prejudicial cutting off funding especially for the “social” professions [read the professions such as college professors, and mental health types, all viewed with varying degrees of suspicion, after all, “social” is close to “socialism” “right here in River City” to utilize the wholesome hysteria of the movie “The Music Man,” of decades ago].
The Reagan era saw the indirect slashing of funding of many postgraduate medical training programs, “residencies,” when the rule was enacted preventing the diversion or allocation of Federal health care reimbursement monies, meaning Medicare and Medicaid monies to help fund such training programs in teaching and university teaching hospitals. This hurt all programs but more so the low revenue producing psychiatry residency training programs that tended to predominantly treat low-income populations in their inpatient units and outpatient clinics; their costs had to be essentially borne by the teaching hospitals. Medicine, pediatric, and especially surgical residencies did not suffer so much as their trainees could do procedures which could be billed for at nicely profitable rates and amounts. Not so in psychiatry where “procedures” were only interviews, lengthy, not brief, face to face contacts. And this was in the day of NON-parity of mental health treatment coverage, where such interventions were reimbursed typically at FIFTY percent of, or half the rates of the more medical-surgical specialties.
All the organized protests predicting a psychiatrist shortage fell on deaf ears for decades. Monitors and observers, and policy wonks and planners, inside and outside of psychiatry were able to predict with uncanny accuracy that coming crisis. All they had to do was tabulate the baby boomer population bulge of psychiatrists by the 1980’s, predict their retirement and death rates and come up with the shortage, once the attrition and cutbacks i psychiatry training slots began nationwide through the 1980’s. Training programs went out of business. Psychiatry slots were reduced in most programs in the country as psychiatry trainees are expensive to train. Face to face time-consuming supervision of individual and group psychotherapy skills is very expensive requiring the time of a faculty member. Similar supervision is required much of a whole day of a psychiatry resident running a ward by himself/herself and requiring the close at hand supervision and on the spot teaching and mentoring of a supervision faculty responsible for that ward.
So now for the last several years it has dawned on the politicians, budget makers, policy planners that there is a dire shortage of such practitioners. This is clearly one of the largest causes of the crisis in the national mental health delivery system that has been in the news for the last several years. To snatch a quote from the above-cited article: the supply of psychiatrists from 2003 to 2013, compared to changes in the supply of primary care physicians and neurologists…the number of practicing psychiatrists declined from 37,968 to 37,889, which represented a 10.2 percent reduction.” The reduction of only a 100 or so psychiatrists at first glance, might not seem significant until one apprehends that context that over a ten year period, not only did the number not increase but actually declined.
My own training program went from training usually 16 adult psychiatrists a year to just 6. Its child psychiatric fellowship reduced its output by two-thirds. This has occurred in most training programs in the country. And I ask once again, is it any surprise that we have the situation we have presently?
The recently approved major mental health funding act, the “Helping Families in Crisis,” bill doggedly ushered through our stagnated, gridlocked Congress just these past two weeks, by Rep. Tim Murphy, goes a long way toward correcting this 30-year crisis in the making. But it will be several years before we see the first fruits of the parts of the bill that beef up the production of mental health professionals of all disciplines which it wisely encompasses as we do not just need more psychiatrists; we need more of every profession in the national delivery of mental health care.