Nearly half of Americans will need mental health care in their lifetimes to treat issues such as mood or substance-use disorders. According to the Department of Health and Human Services, 127 million Americans live in areas with a shortage of mental health professionals.
Prompted by the shortage, states such as Virginia are studying whether to give prescriptive power to psychologists. But physician experts have warned that doing so is not a safe or effective option. They also caution against improperly diverting psychologists from the vital behavioral health treatment they’re uniquely trained to provide.
The way forward should include expanding access to telemental health services, focusing on mental health parity and expanding federal funding for additional residency slots. But one answer offers the potential to dramatically increase the number of patients that psychiatrists can treat: collaborative care.
“There are solutions that are proven that work to not only advance access to care, but to advance access to high-quality, evidence-based and measurement-based care,” said Rebecca Weintraub Brendel, MD, JD, associate professor of psychiatry at Harvard Medical School and chair of the AMA Council on Ethical and Judicial Affairs.
“Collaborative care empowers not nonmedical providers but physicians to learn more about mental health and to have the resources of psychiatrists within primary care and other specialty care practices.”
In a collaborative care model (PDF), the patient’s primary care physician leads a team that includes a consulting psychiatrist and potentially a psychologist, social worker or other behavioral health professional. The psychiatrist assists the primary care physician with the management of their patients (such as with diagnosis and treatment planning, along with reviews of particularly challenging cases), and psychologists can provide nonpharmacological interventions such as psychotherapy.
The psychiatrist can therefore aid in the treatment of multiple patients, as well as those who are off-site. Patients get holistic care, and they get it from the health professional who’s best trained to provide it.
The AMA is fighting scope creep, defending the practice of medicine against scope of practice expansions that threaten patient safety and undermine physician-led, team-based care.
Access problems demand proven solutions
There’s agreement on one aspect of the issue: There are not enough psychiatrists in the U.S. to treat everyone who needs help.
Without action, the gap will only widen. The Association of American Medical Colleges has projected that by 2036, there will be a shortage of about 86,000 physicians, a number that includes a potential dearth of 44,900 nonprimary care specialty physicians such as psychiatrists.
Meanwhile, the need for mental health treatment is on the rise. The results of a 2022 survey, issued by CNN and KFF, showed that 90% of U.S. adults believe the country is in a behavioral health crisis, and about half of respondents said someone in their family had experienced a severe mental health issue. The National Institutes of Health estimates that more than 59 million U.S. adults live with a mental illness—that’s more than 23% of the adult population. And the Centers for Disease Control and Prevention has also reported an alarming spike in the suicide rate.
Colorado, Idaho, Illinois, Iowa, Louisiana, New Mexico and Utah allow some psychologists to prescribe medicine. And Virginia lawmakers recently voted to study the possibility of granting prescriptive power to psychologists there. A work group on the topic has been directed to report its findings to state House and Senate committees by Nov. 1, and the AMA recently submitted comments (PDF) to the state’s medical and psychology boards calling any expansion of prescriptive power “well-intentioned” but “neither a safe nor effective option.”
The AMA has policy opposing the prescribing of medication by psychologists. Visit AMA Advocacy in Action to find out what’s at stake in fighting scope creep and other advocacy priorities the AMA is actively working on.
Diverting care is no solution
Psychologists fill an invaluable role in caring for those with mental health conditions. Adding on more responsibilities for which they were not trained will not improve care.
“The wait to see a psychologist is extremely lengthy,” said Dr. Brendel, who also is past president of the American Psychiatric Association. “We need our psychology colleagues as partners in providing high-quality, effective psychotherapeutic interventions, of which there are many. And really, the way to address a shortage of mental health care is to have everyone on an interdisciplinary health care team working to the top of their ability, training and certification.”
How collaborative care works
Strong evidence supports the collaborative care model. Dr. Brendel noted that more than 80 randomized, controlled trials have demonstrated its effectiveness so far, with more arriving each year.
It also “increases the ability of one psychiatrist to be involved in the care of more patients in collaboration with a primary care physician and a care manager—by a factor of about twentyfold,” she said. “That far exceeds even the limited data we have about the numbers in terms of access for psychologist prescribing, but it also is evidence for high-quality, effective, evidence-based care that is on par with individual treatment by a psychiatrist and on par with the standard of care or exceeds it.”
There’s room for expansion of collaborative care in the U.S. Through its Behavioral Health Integration Collaborative, the AMA is working with 11 leading medical associations to help physicians sustainably integrate behavioral health care into their practices, including those in primary care settings. Resources include the BHI compendium (PDF), an implementation framework for practice, along with strategic how-to guides on topics such as substance-use disorder, suicide prevention, billing and coding, and more.
“In collaborative care, you also can have the psychologist in that model and have the PCP [primary care physician] and the psychiatrist consulting, and that has been effective" elsewhere, said AMA member VijayaLakshmi Appareddy, MD, a Chattanooga, Tennessee-based psychiatrist and addiction-medicine specialist and the vice chair of the AMA Council on Legislation. “That model has worked very well. It needs to be done much more in other areas.”
Importantly, collaborative care finds mental health patients where they are and gives them the high-quality treatment that they deserve.
“The majority of persons with mental health conditions are treated in primary care-type settings and by our partners with medical and clinical training: nurse practitioners and, increasingly, some physician assistants as well,” Dr. Brendel noted, adding that only about 10% of patients with mental health conditions are treated primarily by psychiatrists in their offices.
“If we want to think about affecting and making high-quality care available for the most people, it is really about looking to where that treatment is occurring and getting it working smarter, building capacity and working from a place of strength—not introducing a secondary and inferior pathway.”
