Several Trends Shaping Future of Mental Health Care in U.S.

The growing impact of the mental health consumer movement on federal policy and an increased emphasis on health information technology were among influences highlighted in a recently issued compendium of mental health trends.

The report, “Mental Health, United States, 2004,” was released by the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Mental Health Services (CMHS) in March. It aims to provide a snapshot of the federal government's understanding of current mental health services, trends, and statistics that affect the nearly 44 million Americans who suffer from a mental illness in any given year.

Although the biennial compendium is dated 2004, the trends it identifies have continued into this year, said Ken Thompson, M.D., associate director of medical affairs for CMHS.

“This volume does carry with it an important view of the mental health world as seen from CMHS and SAMHSA,” Thompson told Psychiatric News.

Part of that view is the increasingly important role that mental health consumer advocates play in setting federal policy and determining funding. The compendium reported that the number of mental health consumer organizations doubled to about 2,100 from 1990 to 2002.

“Consumer organizations are in a unique position among the organizations serving people with mental illnesses,” stated the report. The observation echoed that of the President's New Freedom Commission on Mental Health, which believes that such groups will take on a larger role in providing information and coordinating services for people with mental illness.

The report said that by their very nature, consumer organizations help to overcome each of the six barriers to mental health care, which it said are stigma, fragmented services, costs, workforce shortages, lack of available services, and not knowing where and how to get care.

Although these organizations many limitations and frequent funding shortfalls, according to the report, they may be the only entities in the community that interact with each of the disparate federal, state, and local agencies and provide integrated services, supports, and opportunities for recovery in one location.

“This is important because the evolution of the consumer movement has a tremendous impact on federal policy,” Thompson said.

HIT Continues Rapid Growth

Another area in which the report identified changes is in the increasingly influential role that health information technology (HIT) plays in psychiatric care, concluding that increased, and “thoughtful” adoption of HIT will be critical to expanding access to care and the quality of care patients receive.

“An urgent need exists to apply modern HIT to these problems,” according to the report. “Our future health may well depend on it.”

Barriers to greater HIT adoption are the need for increased training for health care clinicians who were “educated in the pre-IT era” and data that suggest the public sector lags far behind the private sector in integrating modern IT into leadership and operations.

Improving Primary Care Quality

Although primary care physicians were increasingly sought over the last decade to treat mental disorders, the intensity and adequacy of those treatments remain poor, according to the compendium.

The relationship of psychiatry to primary care is a key trend to track, according to Selby Jacobs, M.D., chair of APA's Committee on Public Funding for Psychiatric Services.

The report, Jacobs said, offers a useful perspective on the issue of primary care mental health care by describing phases in the development of models of collaboration and the importance of chronic care models that originally were developed and tested for depression but now extend to addictions and severe mental illnesses.

“Part of the problem in development of such models is creating appropriate incentives and reimbursement for all the participants, including the psychiatrist,” Jacobs said. “This is an area we might pay attention to on our committee.”

Psychiatric Workforce Growth Slows

Among the many statistics that the compendium collected was extensive information on the state of the U.S. psychiatric profession, including data that showed a decline in recent years in the growth of psychiatry. Although there was a 38 percent increase in the number of U.S. psychiatrists from 1983 to 2002, the rate of growth slowed to less than 1 percent from 2000 to 2002, the most recent year evaluated in the report.

The compendium reported that the increase in the number of new psychiatrists slowed in recent years from a growth spurt during the 1980s. The number of medical students entering psychiatric residencies increased by almost 25 percent in the 1980s, "plateaued" in the 1990s, and decreased by about 8 percent by 2003, according to APA data included in the compendium.

Separate data found similar results more recently, including a slight drop in the number of U.S. medical students matching into psychiatry from 643 in 2006 to 633 in 2007, according to data from the National Resident Matching Program (Psychiatric News, April 6).

Another of the report's findings is that the psychiatric workforce continues to age, with 64 percent of psychiatrists having completed their highest professional degree more than 21 years ago. Psychiatrists under age 45 constituted 46 percent of the psychiatric workforce in 1990, for example, but only 30 percent in 2002, according to data from the AMA.

The compendium also noted changes in the ways psychiatrists have worked in recent years. The segment of psychiatrists working in more than one setting during the course of a week decreased from 76 percent in 1988 to 45 percent in 2002.

In 2002 psychiatrists spent 45 percent of their patient-care time in either an individual or group practice, while hospitals were previously one of the major work settings for psychiatrists. Psychiatrists who reported hospitals as their primary work setting declined from 28 percent in 1988 to 11 percent in 2002.

The report's authors wrote that the increasing administrative role of psychiatrists is “of particular concern, given its impact in decreasing the available psychiatric workforce for direct patient care, especially in light of the increased demand for psychiatric services.”

Despite the decreases in the growth of physicians choosing psychiatry, no reduction has occurred in federal officials' assessment that the field should have a leading role in establishing federal mental health policy, according to Thompson, a psychiatrist.

“From CMHS's and SAMHSA's perspective, we want to maximize the public service that psychiatrists provide,” Thompson said.

A copy of the compendium is posted at<http://mentalhealth.samhsa.gov/publications/allpubs/SMA06-4195/default.asp>.▪