Psychiatry Workforce and Psychiatry Recruitment: Two Intertwined Challenges

Antidepressant Prescription Behavior Among Primary Care Clinician Providers After an Interprofessional Primary Care Psychiatric Training Program

Primary care providers (PCPs) are increasingly called upon to screen for and treat depression. However, PCPs often lack the training to diagnose and treat depression. We designed an innovative 12-month evidence and mentorship-based primary care psychiatric training program entitled the University of California, Irvine (UCI) School of Medicine Train New Trainers Primary Care Psychiatry (TNT PCP) Fellowship and examined whether this training impacted clinician prescription rates for antidepressants. We retrieved information on 18,844 patients and 192 PCPs from a publicly insured health program in Southern California receiving care between 2017 and 2021. Of the 192 PCPs, 42 received TNT training and 150 did not. We considered a patient as exposed to the provider's TNT treatment if they received care from a provider after the provider completed the 1-year fellowship. We utilized the number of antidepressant prescriptions per patient, per quarter-year as the dependent variable. Linear regression models controlled for provider characteristics and time trends. Robustness checks included clustering patients by provider identification. After PCPs completed TNT training, "exposed" patients received 0.154 more antidepressant prescriptions per quarter-year relative to expected levels (p < 0.01). Clustering of standard errors by provider characteristics reduced precision of the estimate (p < 0.10) but the direction and magnitude of the results were unchanged. Early results from the UCI TNT PCP Fellowship demonstrate enhanced antidepressant prescription behavior in PCPs who have undergone TNT training. A novel, and relatively low-cost, clinician training program holds the potential to empower PCPs to optimally deliver depression treatment.

Utilizing the mental health nursing workforce: A scoping review of mental health nursing clinical roles and identities

Despite rising international needs for mental health practitioners, the mental health nursing workforce is underutilized. This is in part due to limited understandings of their roles, identities, and capabilities. This paper aimed to collate and synthesize published research on the clinical roles of mental health nurses in order to systematically clarify their professional identity and potential. We searched for eligible studies, published between 2001 and 2021, in five electronic databases. Abstracts of retrieved studies were independently screened against exclusion and inclusion criteria (primarily that studies reported on the outcomes associated with mental health nursing roles). Decisions of whether to include studies were through researcher consensus guided by the criteria. The search yielded 324 records, of which 47 were included. Retained papers primarily focused on three themes related to mental health nursing clinical roles and capabilities. Technical roles included those associated with psychotherapy, consumer safety, and diagnosis. Non-technical roles and capabilities were also described. These included emotional intelligence, advanced communication, and reduction of power differentials. Thirdly, the retained papers reported the generative contexts that influenced clinical roles. These included prolonged proximity with consumers with tensions between therapeutic and custodial roles. The results of this scoping review suggest the mental health nurses (MHNs) have a wide scope of technical skills which they employ in clinical practice. These roles are informed by a distinctive cluster of non-technical capabilities to promote the well-being of service users. They are an adaptable and underutilized component of the mental health workforce in a context of escalating unmet needs for expert mental health care.

Revisiting the ATP 30: the Factor Structure of a Scale Measuring Medical Students' Attitudes Towards Psychiatry

OBJECTIVE

Among the scales developed for assessing medical students' attitudes regarding psychiatry, "attitude towards psychiatry-30" (ATP-30) is probably the most widely used. Although this scale was originally deemed to form a unitary dimension without any meaningful subscales, the authors sought to re-examine its factor structure and the viability of subscales.

METHOD

Secondary data from a survey of 743 final-year medical students from nine medical schools in Sri Lanka were analyzed using exploratory factor analysis (EFA) with promax rotation and confirmatory factor analysis (CFA), to assess the underlying factor structure of ATP-30. Parallel analysis was used in determining the number of factors to retain. Items conceptually external to the emerging factors were discarded.

RESULTS

Three models based on literature (one-, five-, and eight-factor) were disproved by CFA. A six-factor solution encompassing 18 items was supported by EFA and CFA and was gender-invariant. These factors were, namely, the image of psychiatrists, psychiatric patients and mental illness, the efficacy of treatment, psychiatric teaching, career choice, and psychiatry as an evidence-based discipline. While "the image of psychiatrists" formed the most consistent subscale (ω = 0.71), the internal consistencies of the other subscales were modest (ω = 0.55-0.67). The overall 18-item scale showed good internal consistency (ω = 0.78).

CONCLUSION

The findings provide evidence of a multi-dimensional structure in medical students' attitudes towards psychiatry, endorsing six meaningful subscales of the ATP-30. Future researchers and educators can utilize these subscales in identifying specific areas where students' attitudes are more stigmatized, to be intervened during undergraduate training.

Generosity of state insurance mandates and growth in the workforce for autism spectrum disorder

LAY ABSTRACT

To improve access to health services for children with autism spectrum disorder, US states have passed laws requiring health insurers to cover autism-related care, commonly known as state insurance mandates. However, the features of mandates differ across states, with some state laws containing very generous provisions and others containing very restrictive provisions such as whether the mandates include children aged above 12 years, whether there is a limit on spending, and whether there are restrictions on the types of services covered. This study examined the relationship between generosity of mandates and growth in the health workforce between 2003 and 2017, a period during which 44 states passed mandates. We found that states that enacted more generous mandates experienced significantly more growth in board-certified behavioral analysts who provide behavioral therapy as well as more growth in child psychiatrists. We did not find differences in the growth of pediatricians, which is a less specialized segment of the workforce. Our findings were consistent across eight different mandate features and suggest that the content of legislation may be as important as whether or not legislation has been passed in terms of encouraging growth in the supply of services for children with autism spectrum disorder.

A Survey of Psychiatry Course Offerings for Fourth-Year Medical Students

OBJECTIVE

Fourth-year course offerings seem to vary widely among psychiatry departments with some offering a wide selection while others offer little or unspecified opportunity. The purpose of this study was to learn the distribution and diversity of fourth-year medical school psychiatry courses and identify unique course offerings that may inspire other departments.

METHODS

The authors compiled a list of US allopathic medical schools accredited by the Liaison Committee on Medical Education (LCME) using the LCME website. They accessed each school's website catalog and recorded all psychiatry electives available to fourth-year students listed in the catalog or the Visiting Student Application Service® (VSAS®) database. The authors calculated median published course offerings per department and categorized each course according to learning opportunity.

RESULTS

The authors identified 142 fully accredited allopathic medical schools of which n = 126 listed fourth-year medical student courses on their website or through VSAS. The median number of fourth-year psychiatry course offerings per school was 6 (range, 1-22). The most frequently offered courses were inpatient psychiatry (n = 105 schools), child and adolescent psychiatry (n = 95), and consultation psychiatry (n = 84). The authors also identified unique enrichment courses in media, women's health, ethics, research, and cultural psychiatry.

CONCLUSIONS

The fourth-year curriculum varies widely among institutions. Hypotheses to be tested are if prioritizing robust fourth-year rotations include improved resident readiness, improved retention of home students into the training program, improved recruitment of visiting students, increased faculty scholarly activity and career development, and improved recruitment into the subspecialties.

Psychiatrist Participation in Private Health Insurance Markets: Paucity in the Land of Plenty

OBJECTIVE

Access to specialty mental health care may be poor because many psychiatrists do not accept health insurance reimbursement, whereas many patients rely on insurance to help pay for care. The objective of this study was to examine the extent of participation in private insurance by licensed psychiatrists.

METHODS

Using 2013 Massachusetts licensing data and the All-Payer Claims Database (APCD), the authors performed a cross-sectional analysis of licensed psychiatrists in Massachusetts. The fraction of psychiatrists who filed insurance claims, number of unique patients with insurance claims per psychiatrist, and physician characteristics associated with insurance participation were evaluated.

RESULTS

In 2013, Massachusetts had 2,348 licensed psychiatrists. Overall, 79% (N=1,843) had at least one paid claim for an outpatient visit in the APCD, but only 6% (N=151) had claims for at least 300 patients per year (a full caseload). Psychiatrists had a median of 18 patients with claims (mean=73). Compared with psychiatrists 30-39 years since medical school graduation, those within 19 years since graduation were less likely to bill for an outpatient (7-19 years, odds ratio [OR]=0.67, 95% confidence interval [CI]=0.47-0.94) and less likely to have claims for ≥300 patients per year (7-19 years, OR=0.49, 95% CI=0.29-0.83). Participation varied across insurance types (93% for group commercial plans versus 33% for Medicaid managed care plans).

CONCLUSIONS

Among Massachusetts psychiatrists, participation in the private insurance market appears to be limited. Older psychiatrists are more likely to participate, and patients' access to psychiatrists who accept insurance could worsen as these psychiatrists retire.

Remote Telepsychiatry Workforce: a Solution to Psychiatry's Workforce Issues

PURPOSE OF REVIEW

The purpose of this paper is to demonstrate how a remote workforce may increase access to care while reducing physician burnout. We review workforce issues and organizational and individual obstacles for implementing a telepsychiatry workforce including administrative, logistical, and clinical considerations and offer resources for how to overcome barriers that may arise in implementing a remote workforce.

RECENT FINDINGS

There is an increasingly unmet demand for mental health services and a shortage in psychiatrists. Burnout may be a key factor contributing to psychiatrists working less, pursuing less acute cases, and leading to worsened outcomes for patients and the psychiatrists themselves. Telepsychiatry provides comparable patient and provider satisfaction and equal outcomes when compared with face-to-face encounters. We provided 3 case examples to demonstrate psychiatrists demonstrating successful delivery of care in a range of clinic settings and workplace configurations while optimizing their quality of life and reducing their risk of burnout.

Mental health delivery in primary care: The perspectives of primary care providers

PURPOSE

To explore perspectives of primary care providers (PCPs), including physicians and nurse practitioners (NPs), about delivery of mental health care in primary care settings.

METHODS

We used a qualitative descriptive designed convenience sample of physicians (N = 12) and NPs (N = 14) through face-to-face interviews in New York State.

RESULTS

Three themes emerged: 1) prioritization of patient needs; 2) applicability of mental health care in primary care settings; and 3) physician and NP approaches to mental health care.

CONCLUSIONS

PCPs recognized importance of addressing patients' mental health care needs and barriers in primary care practices.

Advancing the Mission of Consultation-Liaison Psychiatry Through Innovation in Teaching

BACKGROUND

Consultation-liaison (C-L) psychiatry, similar to other medical specialties, relies on the education of students, residents, fellows, and life-long learners for growth of the field. C-L psychiatry is unique as it exists at the intersection of psychiatry with other medical subspecialties. Traditional teaching methods have been used in C-L psychiatry programs for more than 50 years, while technology has recently advanced as available resources and the learning styles of today's learners have evolved. A growing number of younger trainees are taking advantage of new ways to learn.

OBJECTIVES

We sought to examine both traditional and novel teaching methodologies and how each of these educational methodologies fits within adult learning theory and in the context of how digital natives learn about C-L psychiatry.

METHODS

In this narrative review, we drew upon the experiences of the authors as both life-long learners and educators. We then reviewed the literature pertaining to teaching methods that have been used in C-L psychiatry as well as emerging methods that could potentially be used in C-L psychiatry.

RESULTS

C-L psychiatry has used traditional teaching methods such as readings, didactic lectures, case-based rounds, and problem-based learning. Novel teaching methodologies such as teaching rotations, simulations, social media, podcasts, movie clubs, and the use of mobile tablet computers have been used in general psychiatry and other medical specialties, while literature specific to C-L psychiatry was sparse.

CONCLUSIONS

Opportunities abound to make use of new teaching methodologies and technologies to appeal to future generations of C-L psychiatrists.