California Report Predicts Psychiatrist Shortage

Demand for the services of psychiatrists and mental health professionals in California is likely to increase by as much as 30 percent in the coming decade, while the supply of psychiatrists and most allied mental health professionals in the state is likely to fall woefully short—except for psychologists.

So concludes a report by the California Workforce Initiative of the University of California at San Francisco Center for the Health Professions.

The report, “The Mental Health Workforce: Who’s Meeting California’s Needs?,” attempts to describe the “ecology” of mental health services in the state, with workforce projections not only for psychiatrists and psychologists, but the entire range of allied mental health professionals.

Tina McRee, M.A., a staff research associate at the center and co-author of the report, said that the shortages will be particularly acute in the area of child and adolescent psychiatry and geriatric psychiatry. “The lack of specially trained professionals to deal with children and the elderly is appalling,” McRee told Psychiatric News.

She particularly emphasized the acute nature of the shortage of professionals equipped to diagnose and treat conditions in the elderly. “We are heading toward a crisis for the fastest-growing segment of our population,” she said.

Beyond a general shortage of professionals for meeting a rising need—a finding that hardly surprises psychiatrists familiar with workforce issues—the lengthy report also documents a dearth of information about many aspects of the mental health workforce in California, a mirror reflection of the national picture.

A principal recommendation of the report is the importance of moving toward a “demand” model of patient care that identifies mental health needs and then determines the number and qualifications of professionals necessary to meet those needs.

The report recommends that the state “develop and maintain valid baseline occupational data for the state’s mental and behavioral health care workforce. . . .Currently, the only reliable and comprehensive enumerative and salary data come from government labor surveys, but these rely on job titles that may not reflect actual numbers of graduate-trained, certified, or licensed personnel. Collection and coordination of other data from licensing boards and county and state human resources departments could produce a baseline more reflective of the actual workforce and more useful to policymakers, educators, and administrators.”

Working in the Dark

The dearth of reliable information about the wide variety of mental health practitioners meant that the center’s own methods for projecting a shortage fell short of scientific.

McRee said the center used general labor-force statistics for professional categories that were similar to those for which real numbers were lacking—such as occupational and recreational therapists, psychiatric technicians and social workers, and others. Historical growth rates in all of the professional categories were compared with projected population growth to determine future profession-to-population ratios.

In the meantime, McRee suggested that policymakers attempting to plan for the future are working in the dark. “In terms of planning for the future, we need to address the fact there are very few data available to describe the mental health workforce in California,” she said.

Data on Psychiatry

Of all the mental health professions, it would appear that the clearest picture emerges for psychiatry. And the picture is one of an aging profession, largely white and male, predominately working in office-based settings, and principally located in or around large urban centers.

According to the report, which relied on statistics from the American Medical Association, there were 4,870 active, direct-care psychiatrists in the state in 2000. Of these, 75 percent were male, over half were over 55 years old, 65 percent were white, and nearly 88 percent worked primarily in an office-based setting.

This definition of “active, direct-care psychiatrists” included those working more than 20 hours per week in regular practice with major practice activity in direct patient care. Residents, federal physicians, and psychiatrists whose major professional activity was teaching, research or administration were not included in this category. Also, while the report provides some data on the geographic distribution of psychiatrists within California, the practice location of almost half of the psychiatrists was not available.

“In California, doctors begin to cut back on work hours around age 50,” McRee told Psychiatric News. “If that is the pattern for physicians generally, and over half of the psychiatrists are over 55 years of age, then we are looking at a shortage not just in the number of psychiatrists, but also in the number of hours of service being provided.”

The report also emphasizes what it calls a decline in the number of medical students choosing psychiatry as a specialty—a point that was disputed by psychiatrist Fred Sierles, M.D., past chair of the APA Committee on Workforce Issues.

Sierles noted that there has been a steady, though modest, increase in the number of students matching into psychiatry residency programs in recent years (Psychiatric News, May 3, 2002).

National Phenomenon

Others say the shortage of specialists, particularly in geriatric and child and adolescent psychiatry, is reflective of a well-known national phenomenon (Original article: see box).

Francis Lu, M.D., a professor of psychiatry at the University of California at San Francisco, hailed the report. “It’s a very good strategy to have a more independent organization do this kind of workforce assessment state by state,” he said. “Hopefully, this kind of document could be useful in lobbying efforts to sustain psychiatric residencies.”

Lu, who is chair of APA’s Council on Minority Mental Health and Health Disparities, added that California’s large and growing minority population is another area of need.

“One-third of the state is Latino and Spanish speaking,” Lu said. “There is a great demand for Latino and Spanish-speaking psychiatrists in the state. Studies have shown gross underutilization of services by the Latinos, at least among the Medicaid population. We are trying to understand the reasons for this, but we believe one factor is the lack of Spanish-speaking psychiatrists.”

Too Many Psychologists?

Yet despite the projected overall shortage of mental health practitioners, the center predicts that there may actually be too many psychologists in the future.

There were about 11,000 licensed psychologists in California in 2001, more than 30 per 100,000 residents.

And even more than psychiatrists, psychologists are clustered predominantly in the San Francisco Bay area and Los Angeles. Ratios of psychologists to population varied widely, from 0 in Glenn, Sierra, and Alpine counties to 144.2 in Marin County.

Between 1990 and 2001, there was an increase in the number of psychologists practicing in California of nearly 30 percent. And the center cites studies showing that psychologists “may be experiencing competitive pressures on their income and productivity due to the expansion of the psychologist labor force over the past few decades.”

The center also cites federal government labor statistics showing that more than 4 out of 10 psychologists in the United States were in independent practice in 2000, but that job growth for psychologists through the year 2008 will be moderate, with almost no growth in independent practice.

“Occupational indicators such as low projected job growth and declining salaries and productivity levels suggest that California may be facing an oversupply of psychologists,” the report states.

The report, “The Mental Health Workforce: Who’s Meeting California’s Needs?,” is posted on the Web at www.futurehealth.ucsf.edu/CWI/mntlbeh.htm. ▪