It is evident that mental health issues are a pressing concern for Americans today. Over 40 million Americans report anxiety issues, with an incredible rise concentrated among young adults. Most young people can point to friends, neighbors, or coworkers who have admitted their mental health struggles. Our media is filled with announcements to “end the stigma” surrounding mental health, to encourage people to be open about mental health and offer options for people to find treatment. The repercussions of mental health issues have undeniably permeated our lives.
The deteriorating mental health of Americans is a long-running trend. Deaths of despair—which include suicide, drug overdose, and alcoholism—began rising in the 2000s, concentrated in our hollowed-out communities. A combination of fear, isolation, and financial worries that sprang from the pandemic and our response caused a sharp uptick in anxiety and depression. For young people, a return towards normalcy has not erased the damage.
Poor mental health is costly from an economic perspective. It can worsen job performance and limit entrepreneurship. Mental health issues account for almost one-third of those on Social Security Disability Insurance (SSDI). The annual cost of depression alone exceeds $300 billion. But that pales in comparison to the toll it takes on our personal lives. Anxiety and depression affect family life, fracture friendships, and weaken our communities. They are more than minor inconveniences for sufferers: persistent symptoms are a barrier to our personal and social lives, leading to more withdrawal and a worsening of symptoms.
Needless to say, the deterioration of our mental health has wide-ranging consequences for our health, families, businesses, and communities. While access to timely, quality care is important, patients often face long wait times caused by a shortage of qualified personnel in their area. Understanding what drives these shortages is essential to designing solutions to ensure those suffering have access to mental health treatment.
Diagnosing The Problem
Americans receive mental health treatments from a number of providers in different professions. When we think of mental health care, we typically imagine psychiatrists and psychologists. Psychiatrists are medical doctors, licensed as physicians who specialize in mental health. Psychologists obtain a doctorate degree. Like psychiatrists, they focus on mental health. But not being physicians, their treatment is less medical and does not rely on medication.
Those in other professions also provide mental health treatment. Licensed Clinical Social Workers (LCSW) obtain a master’s degree and are concerned with meeting individuals’ basic needs, including treatment for mental and behavioral issues. Licensed Marriage and Family Therapists (LMFT) also require a master’s degree. They focus on mental health issues within a family context. Additional providers can be found in other professions. Advanced Practice Registered Nurses (APRN) who focus on mental health, professional counselors, and psychological associates provide some treatment as well. All of these require a license to work, postgraduate training, and years of hands-on experience.
Despite the number of different professions able to provide treatment for mental health, we suffer from a shortage. Compounding this problem, state governments create barriers that prevent other qualified professions from filling the gap. Let’s start with the extent of the shortage of mental health professionals. The number of active psychiatrists fell by 10 percent from 2003 to 2013. The number of psychiatrists is projected to fall again through at least 2024, even as the number of people that require their services grows. Similarly, the number of psychologists per person has fallen, although not to the same extent.
But even these frightening figures hide the true extent of the problem. Psychiatrists tend to practice in metropolitan areas, not rural ones. The regional variation in mental health professionals exacerbates the shortages. Over 150 million people live in a mental health shortage area, covering 4,000 different counties. People residing in these counties face a choice, go without mental health treatment, find a different type of provider, or travel to another county. For example, while someone in New York City may have a large number of psychiatrists to choose from, in half of the counties in the United States, patients have no direct access to psychiatric care, forcing them to rely on other professionals—or go without treatment.
Just how much does this shortage hurt patients? In areas without a severe shortage, it takes between six and eight weeks to be evaluated by a psychiatrist and receive a prescription, if necessary. In areas with a shortage, it takes much longer. Long wait times can allow mental health to slowly deteriorate. But in times of mental health crisis, long wait times can be deadly. Areas suffering from provider shortages have significantly higher rates of suicide. Individuals with serious mental health issues living in shortage areas have higher rates of hospital admissions.
Imagine a person seeking mental health treatment for depression. Outside of a metro area, they will have few options, each with a long wait time. In the more than two months it takes to see the psychiatrist, their depression will continue and likely worsen. Determining which drug is best and the proper dosage takes time and numerous appointments. From there, if they need regular visits for therapy, the appointments will not be conveniently located, and the times between appointments may be long because of the number of other patients.
Why Do These Shortages Exist?
Mental health professionals must obtain a license to practice. Licensing laws are designed to protect patients from low-quality mental health treatment. Because it can be difficult for patients to discern good treatment from bad, states set entry requirements for those professions to ensure a minimum level of competency. Licensing requirements include education, hands-on training, and exams. The goal is twofold; ensure the quality of professionals and allow consumers to be confident that the professional they chose is safe.
Economists like to say that there is no such thing as a free lunch, and it’s true that licensing laws come with tradeoffs. The entry requirements that are meant to prevent the unqualified and low-skilled from practicing also increase the cost for those who have the ability. Tuition for college and graduate school is expensive. There are also opportunity costs of education, such as the years of earnings foregone to earn the degrees. And there are additional costs, like exam fees and licensing fees. These fees add up, especially for someone who has not begun to earn an income.
As a result, some opt for other fields with fewer hoops to jump through and that require less time in school. This may sound trivial, but it has a real effect on career decisions. Economists estimate that licensing laws reduce the number of professionals in a field by up to 27 percent. While some are people who would be unable to meet the requirements, doubtlessly many others have what it takes. Objectively measuring quality is difficult, but when we can, we consistently do not find evidence that licensing improves the quality of services, suggesting that the bulk of those prevented from practicing are not low-skilled.
Licensing requirements, and the barriers to entry they create, vary between professions. Psychiatrists are licensed as physicians and specialize in mental health. As a result, they must complete four years of graduate medical education, four years of residency, and pass a series of exams. Psychologists have slightly lower requirements. They must obtain a master’s or doctorate degree, depending on the state. After graduation, they have to work under the oversight of a licensed psychologist for 1,500 to 4,000 hours. LMFTs and LCSWs have similar requirements. They both must obtain a master’s degree in their discipline and have between 1,000 and 4,000 hours of supervised practice, depending on the state. All of these professions have to pay fees, pass licensing exams, and pass background checks.
Besides restrictions on who can enter the profession, licensing laws also limit what tasks a mid-level professional can do. In response to the growing complexity of healthcare delivery, states have clearly defined professional roles and the tasks that they are allowed to perform. These are referred to as scope of practice laws. Most states only allow psychiatrists to prescribe medication, currently just five states allow psychologists to do so. LMFTs and LCSWs are even more limited, and in some cases unable to diagnose and treat conditions like anxiety and depression, although that can vary between states. By preventing mid-level professionals from providing care, scope of practice laws prevent these professionals from filling the gap left by a shortage of psychiatrists.
What Can We Do?
Recognizing the difficulty caused by a shortage of mental health professionals and building upon our past work, we can provide some recommendations. Any attempt to increase the supply of professionals by reducing the barriers to entry, while still maintaining patient protection, is a step in the right direction. But simply allowing low-quality professionals to begin practicing will not be an effective long-term solution.
Increasing the supply of psychiatrists involves more than simply reforming state licensing laws. Any solution requires reforms at multiple levels of government. The causes of the physician shortage, which affects psychiatrists, has been well-covered by Robert Orr. It involves a number of players and extends beyond state licensing laws. While these reforms are worthwhile and should be pursued, states do not have the ability to solve the shortage through simple reforms. For the near term, we will not be able to meaningfully increase the number of psychiatrists.
A simple solution that will allow us to use existing resources more effectively, providing an immediate benefit, would be to allow psychologists to prescribe psychotropic medication. Around half of counties in the US lack a psychiatrist, and psychologists can fill that gap. Allowing psychologists to prescribe medication would improve access for patients with the most pressing needs. States that have already allowed psychologist prescriptive authority have more psychologists and no evidence of negative outcomes for patients. They find evidence that some counties saw their first psychologist open a practice after prescriptive authority reform.
LMFTs and LCSWs are additional sources of professionals who can provide diagnosis and treatment of anxiety and depression. Currently, scope of practice laws allow LCSWs to diagnose and treat depression in 47 states. On the other hand, LMFTs are allowed to diagnose and treat these conditions in just 30 states, completely prohibited in Kentucky, and in the remaining states, regulatory language is unclear. Because practicing outside of your profession’s scope of practice results in disciplinary actions, including losing their license, ambiguity is often as bad as outright prohibition. LMFTs and LCSWs can be used to fill in the gap when an area lacks an adequate number of psychiatrists and psychologists. States should clarify that these professions have the authority to provide diagnosis and treatment for simple conditions like anxiety and depression.
To facilitate entry into the LMFT and LCSW professions, states should reduce and standardize clinical education hours. Experience practicing under the supervision of a licensed professional is important to develop the skills of a mental health professional, especially if they will be practicing independently. However, there is a wide variation in supervised practice requirements between states, ranging from 1,000 to 4,000 hours of experience. This variation suggests that the requirements are being determined by something other than quality. Despite having the same education requirements, only 22 states require the same number of hours of experience from LMFTs and LCSWs. Considering the similarity between the professions, we would expect more overlap. States with the most restrictive supervised practice hours should reduce them to the national average, between 2,000 and 3,000 hours.
Finally, states should reduce the cost of obtaining and maintaining licensure for LMFTs and LCSWs. This is a simple way to encourage people to enter the professions. While this reform will not be a panacea to a lack of access to mental health treatments, we should not be throwing up unnecessary barriers. The costs for initial licensing include exam fees, application fees, and initial licensing fees. The average total cost of initial licensing is $611 for LMFTs and $431 for LCSWs. Once licensed, professionals have to pay for continuing education and licensing renewal fees. On average, an LMFT will pay $4,859 for licensure in the course of their career and an LCSW will pay $3,336. Reducing these fees to the minimum necessary to administer the licensing board will reduce the costs of licensure.
There is no simple policy solution to improve the mental health of Americans, too many of whom are struggling. However, expanding access to qualified mental health professionals is one way to help the growing number of those who suffer from conditions like anxiety and depression. Removing laws that stand between providers and patients is the quickest and simplest method to help improve mental health. Well-intentioned laws can still cause harm, and ensuring that our licensing laws for mental health professions protect patients without sacrificing their access to treatment is the first step.