Employing Nurse Practitioners and Physician Assistants to Provide Access to Care as the Psychiatrist Shortage Continues

Multiple Stakeholder Perspectives of Implementing Work-Related Cognitive Behavioral Therapy (WCBT) in Vocational Service Settings: A Qualitative Exploration of Intervention Acceptability and Sustainability

Growing mental health treatment access disparities elevate the urgency for identifying and implementing innovative approaches for delivering evidence-supported interventions. Work-related cognitive behavioral therapy (WCBT), a technology-assisted CBT (t-CBT) designed to address social anxiety and employment outcomes among job seekers at vocational service centers and for delivery by vocational service professionals, offers a promising way to increase access to needed mental health care. This qualitative study, guided by the Organizational Transformation Model (OTM), explored factors related to WCBT's implementation at two Jewish Vocational Services (JVS) Human Service sites in Detroit, MI and Los Angeles County, CA. Twenty-seven staff-stakeholders across the two JVS sites completed in-depth, semi-structured interviews focused on their experiences with WCBT over the four-year study period. Thematic analysis identified five core codes that most broadly captured participants' perceptions of WCBT implementation and the factors influencing implementation, including: (1) Need, (2) Buy-in and engagement, (3) Communication, (4) Sustainability concerns, and (5) Implementation facilitators. Core codes aligned with OTM factors related to impetus to transform, improvement initiatives, integration across boundaries, alignment from top to bottom, and leadership. Findings identify implementation strategies likely to optimize uptake and sustainability of WCBT within JVS sites that can be tested in a larger, multi-site implementation trial.

Physician assistants/associates in psychiatry: a workforce analysis

BACKGROUND

Physician assistants/associates (PAs) provide services in diverse medical specialties globally, including psychiatry. While health professionals in psychiatry have been described for many years, little is known about PAs practicing in this discipline.

METHODS

We describe US PAs practicing in psychiatry using robust national data from the National Commission on Certification of Physician Assistants (NCCPA). Analyses included descriptive and inferential statistics comparing PAs in psychiatry to PAs in all other medical and surgical specialties.

RESULTS

The percentage of PAs practicing in psychiatry has increased from 1.1% (n = 630) in 2013 to 2.0% (n = 2 262) in 2021. PAs in psychiatry differed from PAs practicing in all other specialties in the following: they identified predominately as female (71.4% vs. 69.1%; p = 0.016), were more racially diverse (Asian [6.6% vs. 6.0%], Black/African American [5.5% vs. 3.4%], multi-race [2.8% vs. 2.1%], and other races [Native Hawaiian/Pacific Islander, American Indian/Alaska Native, or other; 3.7% vs. 3.6%]; p < 0.001), and resided in the South (43.8% vs. 34.1%; p < 0.001). PAs in psychiatry vs. all other specialties were more likely to work in office-based private practice settings (41.6% vs. 37.3%; p < 0.001) and nearly twice as likely to provide telemedicine services for their patients (62.7% vs. 32.9%; p < 0.001). While one-third (31.9%) of PAs in psychiatry experienced one or more burnout symptoms, and 8.1% considered changing their current position, the vast majority of PAs in psychiatry (86.0%) were satisfied with their position.

CONCLUSIONS

Understanding the attributes of PAs in psychiatry is essential in medical labor supply and demand research. Our findings suggest that the number of PAs working in psychiatry is steadily increasing. These PAs were predominantly female, exhibited greater racial diversity, and were primarily located in the South and Midwest regions of the US. A striking difference was that PAs in psychiatry were almost twice as likely to provide telemedicine services for their patients. Although nearly a third of PAs in psychiatry acknowledged having one or more symptoms of burnout, few were considering changing their employment, and the vast majority reported high job satisfaction.

Growing the Psychiatry Workforce Through Expansion or Creation of Residencies and Fellowships: the Results of a Survey by the AADPRT Workforce Task Force

OBJECTIVE

The USA needs to produce more psychiatrists to meet projected workforce deficits. The American Association of Directors of Psychiatric Residency Training Directors (AADPRT) sought to examine opportunities for and obstacles to expanding or creating residencies and fellowships.

METHODS

In November 2019, the authors conducted a survey of residency and fellowship directors. The survey gathered information about new positions, new programs, participation in interprofessional education, and loss of residency or fellowship positions.

RESULTS

The survey was distributed to psychiatry residency (N=231) and fellowship (N=194) directors, with a response rate of 33.4%. One quarter of responding residencies and fellowships reported creating new programs; 24.7% of residency and 17.5% of fellowships reported expansion. The most common reason to develop or expand programs was the shortage of psychiatrists, with the local institution as the most common funding source. Fifty-seven percent reported that they had wanted to expand, but faced barriers, primarily lack of funding. Recruitment and retention of faculty are major challenges. Psychiatry departments frequently (87.5%) participate in interprofessional education, generally perceived as positive. Unfortunately, 15.7% of respondents reported loss of positions or closure of programs.

CONCLUSIONS

Creating and expanding residencies and fellowships are common strategies for addressing the shortage of psychiatrists. Barriers include lack of funding and challenges recruiting/retaining faculty. The loss of residency/fellowship positions or closure of programs is a worrisome trend.

The role of PAs in providing mental health care

The prevalence of psychiatric and substance use disorders in the United States is rising and of growing concern. Because such behavioral conditions are widespread, one approach is to collaborate with various medical professionals to help offset this demand. To address this issue, the frequency and types of mental health conditions encountered by physician assistants (PAs) were assessed. The National Commission on the Certification of Physician Assistants Practice Analysis was examined for the types of mental health conditions encountered across the spectrum of medical and surgical practices. The findings reveal that, in 2015, at least 62% of PAs saw and evaluated mental health conditions and behavioral disorders at least weekly in their settings. These patient diagnoses were seen with variability based on the specialty of the PA. The highest percentage of cases reported by PAs were in psychiatry, followed by general internal medicine, emergency medicine, family medicine, and hospital medicine. With the profession projected to grow, recruiting, retaining, and integrating more PAs into mental health care is a suggested strategy for addressing national provider shortages.

Predictors of hospital admission for patients presenting with psychiatric emergencies: A retrospective, cohort study

BACKGROUND

Rising psychiatric visits represent a significant and growing burden for emergency departments (EDs) across Canada. For individual psychiatric conditions, there are likely a variety of demographic and social variables that may increase risk of resource intensive hospital admission.

METHODS

We conducted a retrospective cohort study of all patients admitted into inpatient psychiatric units from two EDs in Kingston, Ontario, Canada from 2015 to 2018. We collected demographic and social variables from an electronic ED information system inclusive of all patients presenting to the ED with a mental health or addictions-related chief complaint. We used multivariate logistic regression models to identify predictors of psychiatric admission.

RESULTS

A total of 23,814 patients (49.1% male, median age 33) were identified. Admitted patients (n=1838) tended to be older (49 vs. 31 years), have lower Canadian Triage Acuity Scale scores (2.6 vs. 3.0), arrive by ambulance (51% vs. 35%) or police (18% vs. 9%), and have longer lengths of stay (8.4 vs. 4.9 hours). Individuals with mood and psychotic disorders were more likely to require a hospital admission.

CONCLUSION

A variety of clinical and demographic variables increased the risk of hospital admissions for individuals with a variety of psychiatric disorders.

Effects of Brief Depression and Anxiety Management Training on a US Army Division’s Primary Care Providers

Introduction

There is a nation-wide gap between the prevalence of mental illness and the availability of psychiatrists. This places reliance on primary care providers (PCPs) to help meet some of these mental health needs. Similarly, the US Army expects its PCPs to be able to manage common mental illnesses such as anxiety and depression. Therefore, PCPs must be able to close their psychiatric skills gaps via lifelong learning.

Materials and Methods

Following needs assessment of PCPs in a US Army division, the curriculum was developed. Objectives targeted pharmacological management of depression and anxiety. Behavioral intervention skills were also taught to treat insomnia. Didactics and case-based small groups were used. A novel psychotropic decisional tool was developed and provided to learners to assist and influence their future psychiatric practice. Pre-training, immediate post-training, and 6-month assessments were done via survey to evaluate confidence and perceived changes in practice. The curriculum was executed as a quality improvement project using the Plan, Do, Study, Act framework.

Results

Among 35 learners, immediate confidence in selecting optimal psychotropic and perceived knowledge, skill to change the dose or type of medication, and confidence in prescribing behavioral sleep improved significantly with large effect sizes. At 6-month follow-up, learners reported that they were more likely to adjust medications for anxiety or depression and were more likely to start a new medication for anxiety or depression because of the training with moderate effect sizes. Use and satisfaction with the psychotropic decisional tool are also reported.

Conclusions

Our psychotropic decisional tool illustrates a novel algorithmic approach for operationalizing the management of depression and anxiety. Similar approaches can improve the skills of a variety of PCPs in the management of psychiatric disorders. Further studies in the military operational setting are needed to assess the effects of similar educational interventions on access to behavioral health care, suicidal behaviors, and unit medical readiness.

Community-Based Mental Health Treatment Preceding Jail Detention among Adults with Serious Mental Illness

Research on the effectiveness of community-based mental health treatment for offenders with a serious mental illness (SMI) has lacked specifics on the type and intensity of services received. This study examined the detailed lifetime and past-year community mental health treatment use of 431 (282 men; 149 women) jail detainees with SMI. Whereas a majority of participants reported high lifetime rates of mental health treatment they believed effective, treatment in the year and month prior to arrest and detention was accessed by only a minority of the sample. Where gender differences were found, women were less likely to receive treatment than men and more likely to leave treatment against medical advice in the year preceding arrest. Both substance use disorders and post-traumatic stress disorder (PTSD) were significantly undertreated for both genders, and care was provided predominantly by psychiatrists suggesting an underuse of other mental health professionals. The implications for expanding treatment availability for offenders, particularly women, with an emphasis on broadening access to ancillary but critical services such as literacy training, housing and employment services, and case management provided by mental health professionals in conjunction with services provided by psychiatrists are discussed.

Plastic Surgery and Suicide: A Clinical Guide for Plastic Surgeons

Several studies have identified an increased risk of suicide among patient populations which a plastic surgeon may have a high risk of encountering: women undergoing breast augmentation, cosmetic surgery patients, and breast cancer patients. No formal guidelines exist to assist a plastic surgeon when faced with such a patient, and not every plastic surgery team has mental health clinicians that are readily accessible for consultation or referral. The goal of this clinical guide is to offer plastic surgeons a set of practical approaches to manage potentially suicidal patients. In addition, the authors review a screening tool, which can assist surgeons when encountering high-risk patients.