California is suffering a shortage of mental health professionals – and it's expected to get worse in the next decade.
In 2013, California had a shortage of 336 psychiatrists, according to national projections from the Health Resources and Services Administration, cited by the state Governor’s Office.
“That shortage is forecasted to grow to between 729 and 1,848 by 2025,” said Brian Ferguson, Gov. Jerry Brown's deputy press secretary.
The Health Administration designates areas with a shortage of health professionals primarily using ratios between health professionals and population numbers.
"Federal regulations stipulate that, in order to be considered as having a shortage of providers, an area must have a population-to-provider ratio of a certain threshold," according to information published by the Kaiser Family Foundation. "For mental health, the population to provider ratio must be at least 30,000 to 1."
Statistics from The Steinberg Institute, a local nonprofit focused on issues related to mental health and founded by Sacramento Mayor Darrell Steinberg, estimate that demand for psychiatry in the United States “will outstrip supply by 15,600 psychiatrists, or 25 percent” by 2025.
And a study released in February by the Healthforce Center at UC San Francisco projects that California will have a “severe shortage of psychiatrists by 2028." Shortages are defined "as the gap between the supply of behavioral health professionals and demand for behavioral health professionals," explained Janet Coffman, an associate professor in policy at UCSF and an author of the study.
The study identifies current and expected retirement levels as a leading cause of the shortage, as those older than the age of 60 make up 45 percent of psychiatrists and 37 percent of psychologists.
“Many behavioral health professionals, particularly psychiatrists and psychologists, will reach retirement age within the next decade,” the study states.
A 2017 study published by the National Council for Behavioral Health that looked specifically at the shortage of psychiatrists identified causes for the 10 percent decrease in the ratio of psychiatrists to the U.S. population over the 2003-13 time period.
“Aging of the current workforce, low rates of reimbursement, burnout, burdensome documentation requirements and restrictive regulations around sharing clinical information necessary to coordinate care are some of the reasons for the shrinkage,” the study states.
Although the rates of individuals pursuing these professions has remained constant, Coffman said, a growing California population means a growing demand for services. This also means a greater increase in unmet need — those in need of services, but not currently receiving care.
Taking into consideration unmet need is critical, said Maggie Merritt, the executive director of The Steinberg Institute, “just as it would be for any other health issue.”
“The longer they go without care, the more intense care they’ll need,” she said.
Coffman and her colleagues projected future statewide shortages of mental health professionals based on two scenarios: one that looked at the current use of services and one that looked at both current use and unmet need.
For the latter situation, UCSF researchers used data from the federal health administration which estimated that, in 2013, 20 percent of the U.S. population was in need of treatment for mental illness or substance use and/or dependence but did not receive any care.
The study estimates that, in 2016, there was a demand for 6,145 psychiatrists, but the state had a supply of 5,809 psychiatrists. Demand is defined as current utilization of services based on national data from the Health Resources and Services Administration.
“However, in order to provide services to all individuals who needed care in 2016, 7,238 psychiatrists were needed, which indicates a gap of 23.6 percent between the number of psychiatrists in California in 2016 and the number required to care for all persons who need behavioral health services,” the study states. “In 2028, the supply of psychiatrists is projected to decline to 3,833.”
The study differentiated between demand, specifically focused on current utilization rates, and the total number of individuals in need of care, which takes national data related to unmet need into consideration.
Calculated shortages indicate that in one decade, California will have 41 percent fewer psychiatrists and 11 percent fewer psychologists, marriage and family therapists, clinical counselors and social workers than will be needed.
Taking unmet need into consideration, the projections are more drastic. In this scenario, there is an expected 50 percent shortage of psychiatrists and a 28 percent shortage of psychologists, marriage and family therapists, clinical counselors and social workers in 2028.
“Increasing the supply of professionals who can prescribe psychiatric medications is especially critical because the number of psychiatrists is projected to decrease by 34 percent between 2016 and 2028,” the study explains, highlighting a need for “substantial investments” to meet future demand for mental health services.
Merritt said one issue is that universities in California do not have enough residency programs for training mental health professionals. North of Sacramento, there is a complete lack of psychiatry residency programs as well as educational programs for psychologists and psychiatric nurse practitioners, according to the UCSF study.
“Where the residents finish their training is likely where they’re going to continue their practice,” said Dr. Gerald Maguire, a professor and chair of psychiatry and neuroscience at UC Riverside.
Current efforts to address the shortage include Assembly Bill 2018, which would allow loan repayment for trainees who meet the necessary criteria and who commit to programs or facilities operated by county mental health plans.
“The shortage of psychiatrists in the United States and California has reached crisis levels,” said Assemblyman Brian Maienschein, who introduced the bill, in a statement sent to The Sacramento Bee. “AB 2018 will amend current statute for state loan repayment programs to allow trainees that meet necessary criteria to be eligible for loan repayment during their training.”
Recently, the state budget approved $55 million for residency programs. This total includes $40 million for general, nonpsychiatric programs and $15 million to fund psychiatric residency slots and telepsychiatry services at UC Riverside.
Elizabeth Romero, an assistant vice chancellor for the Office of Governmental and Community Relations at UC Riverside, explained that the Inland Empire, like the Central Valley, is considered a medically underserved area. The $15 million of funding will go to fund psychiatry residency spots, she said, targeted to train and attract people interested in providing care in underserved areas.
The $15 million for UC Riverside will also be partially invested in telepsychiatry services, which will allow providers to reach more patients without having to travel. Telehealth technology was specifically identified in the National Council for Behavioral Health’s 2017 study as a means to combat psychiatry shortages and reach underserved areas.
“An additional investment is good news,” Coffman said of the increase in state funds, but she also mentioned that the shortages are a sustained problem, and a one-time investment in the mental health workforce is worrisome, especially when residency programs are several years.
Romero addressed concerns related to one-time funding, saying the UC Riverside hopes “to leverage the funding to support the residency spots throughout the life of the residency.”
"In Riverside County, there are only an estimated 5.29 psychiatrists per 100,000 people, compared to the statewide average of 14.47," according to Romero. "Ratios for psychologists, licensed clinical social workers and marriage and family therapists, also fall substantially below the California average. In addition, there is a severe mal-distribution of child and adolescent psychiatric services in the state, where rural areas and areas of low socioeconomic status have lower access to care."
Furthermore, Romero passed along 2015 data from the American Academy of Child Adolescent Psychiatry that designated Riverside County a "severe shortage area" and estimated the county "actually needs 20 times the number of practicing child and adolescent psychiatrists to sufficiently meet the need."
With seven current residents, Maguire has plans to increase the number to 12 within the next few years. The plan is to expand as rapidly as possible while continuing to meet accreditation guidelines. There is also a goal to focus on underserved efforts in psychiatry, including child psychiatry.
Maguire was born and raised in Butte County, a medically underserved area where his father, age 90, is still a practicing psychiatrist. He said his background was a large factor in his decision to join UC Riverside’s staff, where he aims to serve the community.
The state budget also includes one-time funding of $1 million for the Train New Trainers Primary Care Psychiatry Fellowship, started at UC Davis in 2016.
Primary care providers provide up to 65 percent of mental health care, explained Dr. Robert McCarron, a faculty member at UC Davis and the vice chair of education and integrated care in the Department of Psychiatry at UC Irvine. This fellowship trains health professionals such as family medicine doctors and pediatricians to recognize psychiatric conditions.
“These people all have a very strong and certified background in medicine,” McCarron said. “We’re adding to and augmenting their training.”
Fellows in the program come from rural areas, already serving medically underserved areas.
Most funding for the fellowships comes from counties such as Alameda, an early partner. Without any state funding, there are 68 fellows this year, but McCarron said state support will be critical to exponentially grow the program.
In addition to the lack of psychiatric services in rural areas, psychiatric services can be expensive and unaffordable, and not just for low-income people. It can be difficult for middle-class patients to find a provider, Coffman said.
Specifically, Coffman addressed the 77 percent of psychiatrists who accept private insurance, in comparison to the 46 percent of psychiatrists who have any Medi-Cal patients.
This isn’t an issue specific to mental health care, McCarron said. But billing issues regarding psychiatric care are complicated and need to be looked at more closely, he said.
Of the psychiatrists working nationally, Merritt pointed out, half work on a cash-only basis, further limiting the access to psychiatric care.
There is also a gap, Coffman explained, between what psychiatrists earn who work for the county or the state — who do see Medi-Cal-covered individuals — and the earnings for those who go into private practice in affluent communities.
Dr. Anthony Urquiza, the director of the UC Davis Child and Adolescent Abuse Resource and Evaluation Center, sees about 600 kids a week with 40 to 50 mental health therapists and one child psychiatrist who comes in a few times a week. Ten to 15 percent of patients need some type of psychiatrist-prescribed medication, he said, and if there is no access to a psychiatrist, he’s stuck.
“In Sacramento there are very, very few psychiatrists and even more so, very few child psychiatrists,” Urquiza said, explaining that scarcity drives up the cost of psychiatrists.
There are other issues relating to psychiatric care. Coffman pointed out that current provider demographics do not match the demographics of clients.
In the Sacramento region, 40 percent of active psychiatrists were white as of 2015, according to the UCSF study. Additionally, “male graduates represented larger shares of graduates of clinical or counseling psychology programs” at both master’s and doctoral levels in the region.
Coffman said that people who have issues related to gender and sexuality may feel more comfortable talking with someone who has the same gender or ethnic background as them. But it might even prove challenging to find someone who speaks the same language.
One solution to increase the diversity of providers and address the shortages is stimulating an interest in health fields among kids at an early age – especially for young people who come from rural areas or who are in marginalized groups, Coffman said.
“One of the things that is also important over the long run is opportunities for young individuals in behavioral health,” Coffman said. “We need more people in health care, period.”
The scope of the shortage of mental health professions might not be obvious to those outside the mental health profession, but it's certainly felt, said Deborah Anderluh, director of communications at The Steinberg Institute.
“On one hand, I think people would be surprised by the statistics," Anderluh said. "But on the other hand, I have many friends and colleagues ... struggling to find a professional. Those people are very aware of the shortage.”