More than half of American adults and 80 percent of children with mental-health needs do not receive treatment, according to the U.S. Department of Health and Human Services’s mental-health website.
Some don’t want to seek care and the cost of treatment is a barrier for others. But even those with resources who want care are running into a pervasive problem: There are not enough mental-health care workers in the United States.
“Even speaking broadly — including psychiatrists, psychologists, and social workers — there’s really a huge shortage,” said Jed Magen, president of the American Association of Chairs of Departments of Psychiatry. (The organization represents psychiatry departments at medical schools in the U.S. and Canada.)
The shortage of providers forces people to wait weeks or months for appointments. Experts say it’s likely contributing to the rising rate of suicides across the country and the growing number of people going to hospital emergency departments for mental-health concerns.
Now nurses are raising their hands to fill the gap, but they say state laws are limiting their abilities. The American Psychiatric Nurses Association (APNA) recently published a report detailing the need for more expansive powers for psychiatric nurses.
“Often, people say, ‘I need to see a psychiatrist.’ But you know what? You could see a psychiatric mental health nurse, too,” said Gail Stern, president of the APNA and administrator of the Lehigh Valley Health Network’s department of psychiatry.
Psychiatric mental health (PMH) nurses include both registered nurses and advanced practice nurses. Nationally certified PMH registered nurses have been in the field at least two years and have completed 2,000 hours of mental-health clinical practice and 30 hours of continuing education. PMH advanced practice nurses have additional degrees and licenses in mental-health care.
PMH advanced practice nurses are trained to diagnose mental illness, prescribe medication, and provide psychotherapy. But in Pennsylvania and New Jersey, they’re required to have a supervising physician sign off on any prescriptions.
The APNA says that restriction is unnecessary. “Given the shortage of providers, we want to use the ones we have as well as we can,” Stern said.
Studies show that more than 96 percent of all U.S. counties have an unmet need for mental-health prescribers, and the shortage is most profound in rural areas.
The APNA report points to 21 states that already allow PMH advanced practice nurses to prescribe on their own as models.
Working as a team
Although physician groups have traditionally opposed expanding nurses’ practice parameters, the desperate need in mental-health care may shift some people’s perspectives.
“There will never be enough psychiatrists,” said Magen, who is a practicing child and adolescent psychiatrist and chair of the department of psychiatry at Michigan State University. “It’s really important to be able to use these other professionals to address the shortage.”
Psychiatrists have to go through four years of medical school and four to five years of residency. There’s also a limit on how many can be educated each year, as federal funding limits the number of psychiatry residencies in the country to 1,400.
That’s why Magen advocates for a team-based approach to mental-health care, in which patients see different providers based on their level of need.
For instance, if someone who has been generally functioning well develops depression, a nurse or primary-care physician can likely handle that case well, Magen said. If that person doesn’t respond to therapy or multiple medications, then it becomes a more complicated case that should involve a psychiatrist.
This type of approach works only if all parties are clear on how they contribute to the team, Magen said. “If you just throw people in together without discussions about roles, you are not going to do well.”
Building trust with diverse patients
Recruiting more PMH nurses and expanding their scope of practice may also help address the disproportionate impact of mental illness among racial, cultural, and ethnic minorities in America, Stern said.
Minority communities have high levels of unmet mental-health needs in part because of cost and language barriers, but also due to mistrust of the medical system. Throughout history, minorities have been used in medical experiments without their consent or misled about treatment options.
This is where nurses can act as a bridge, Stern said. Nurses have been ranked the most-trusted profession in the U.S. for 20 years.
“If we think about who can improve the trust, access, and comfort level of people to get mental-health services, we need to say nurses,” Stern said.
But the field has a long way to go in terms of diversifying its own ranks — another component to increasing cultural competence and trust among diverse communities.
Data from the National Nursing Workforce Survey show that 72 percent of PMH nurses are white, and 86 percent are female.
Stern said she hopes getting the word out about job opportunities in this field — there’s been a 58 percent increase in open positions in recent years — will help attract more diverse candidates. It might also be a more feasible path for those unable to take on medical school debt, she said.
“We want people to understand that we are here. This is an option,” Stern said. “It’s a wonderful, fulfilling profession to care about people in this way.”