As the gap widens between the need for mental services and the availability of psychiatrists, consequently, demand for “physician extenders” has increased significantly. Across the country, nurse practitioners (NPs), advanced practice registered nurses (APRNs), and in some cases, physician assistants (PAs), are taking on more of the psychiatric case load.
The availability of these midlevel providers can be invaluable, says Joe Parks, MD, medical director at the National Council for Behavioral Health.
Parks also practices psychiatry at the Family Health Center, a federally funded community health center (CMHC) in central Missouri, where an advanced practice psychiatric nurse and three behavioral healthcare consultants have allowed him to serve roughly eight times as many people than he could if he were treating them himself.
“We will never meet everybody’s needs seeing all of the patients ourselves,” Parks says.
By utilizing the advanced practice nurse, he can spend less time doing routine medication refills, for example, and spend more time with patients who require an in-person consultation. Before, patients waited months to see a psychiatrist.
“In this way I’m always operating much closer to the top of my credentials,” Parks says. “It’s a different kind of work for me. I work harder. I’m able to see many more people and it has really changed my practice.”
Nurse practitioners are playing a key role in extending access to mental health and substance use treatment services, but how they are utilized varies by state. According to the National Council, 21 states and the District of Columbia give NPs full practice authority so that they can diagnose, treat, order diagnostic tests and prescribe to patients without physician oversight. In other states, NPs must work in collaborative practices under the direction of a supervising psychiatrist. Other states restrict NPs ability to prescribe certain medications.
Physician assistants are also emerging as a potential source of help for psychiatric practices. In a paper published in March, titled “The Psychiatric Shortage: Causes and Solutions,” the National Council wrote that “PAs with specialty psychiatric training are a relatively new development that has tremendous potential for expansion. Since their duration of training is the shortest of the psychiatric prescribers, they represent one of the most cost-effective solutions to the shortage of psychiatric workforce.”
Demand is increasing for midlevels. According to data from healthcare job matching site Health eCareers, there was a 17% increase in psychiatric nurse practitioner job opportunities between 2014 and 2015, making the field one of the fastest growing non-physician specialties.
Regulations are starting to shift to make it easier to integrate midlevel providers into these practices. In 2016, federal officials announced the expansion of the ability to prescribe buprenorphine to NPs and PAs with specialized training. The Veterans Administration has also extended full practice authority to NPs across the United States.
Other efforts to leverage midlevel providers to extend psychiatric care are also underway. Several national PA organizations convened a mental health summit earlier this year to identify ways that they can help address the psychiatrist shortage. The groups acknowledge that more work needs to be done to establish a framework to help train PAs for mental health and addiction treatment.
“That’s not downplaying the importance of physicians,” says Tari Dilks, PhD, associate professor of nursing at McNeese State University in Lake Charles, La. “If you can’t find a psychiatrist to collaborate with, you can’t practice in many states.”
Dilks is co-coordinator of McNeese’s Master of Science in Nursing programs and director of the psychiatric/mental health track for the Intercollegiate Consortium for a Master of Science in Nursing partnership and has an active private practice.
She believes that full practice authority will eventually reach all 50 states, and several more are already moving in that direction. Parks, however, thinks that there is a lot of value in collaborative practices that aren’t related to the abilities of NPs.
“I really think we’re better off in collaborative practices,” he says. “Everybody is, including the psychiatrist and the patients.”
The potential to help expand the psychiatric workforce is significant. In 2014, there were 140,000 APRNs, and 13,815 psychiatric mental health APRNs specializing in psychiatry, according to the American Psychiatric Nurse Association (APNA). In addition, approximately 1,000 physician assistants are prescribing psychiatric medications in the U.S. according to the American Academy of Physician Assistants (AAPA). The National Council believes that board certified psychiatric pharmacists can also help meet the demand for services.
NPs and leadership
In psychiatry and in subspecializations like substance use treatment, there is what Genie Bailey, MD, calls “a real market for midlevel providers.”
Bailey is a board certified psychiatrist and director of research and medical director of the dual diagnosis unit at Stanley Street Treatment and Resources in Fall River, Mass. The dual diagnosis unit is run by a skilled nurse practitioner who functions as the unit chief (backed up by a medical director).