Psychiatry 2021: Team Psychiatry

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FROM THE EDITOR

John J. Miller, MD is medical director, Brain Health, Exeter, NH; Editor in Chief, Psychiatric Times^TM; staff psychiatrist, Seacoast Mental Health Center; consulting psychiatrist, Exeter Hospital; consulting psychiatrist, Insight Meditation Society, Barre, MA.

Individuals with mental illness continue to struggle with access to treatment in the United States, including in metropolitan hubs. Despite the huge unmet need for additional psychiatrists in the United States, the number of graduating medical students choosing psychiatry as their specialty training sadly remains quite low. Thomas et al estimated that approximately 96% of the 3140 US counties had an unmet need for practicing psychiatrists, and this need was higher in rural areas and areas with low per capita income.¹ In 2013, 70% of US psychiatrists were over the age of 50,² suggesting this shortage will only increase as current practitioners retire in the years ahead. I live in Exeter, New Hampshire, a mere hour north of Boston, Massachusetts, where the waiting time for an initial outpatient psychiatric evaluation is anywhere from 2 to 6 months.

I was introduced to my first psychiatric mental health advanced practice registered nurse (PMH-APRN) when I joined a private psychiatric group practice in 1995 in Newburyport, Massachusetts. This was a multispecialty outpatient practice with a wide range of clinical specialties: therapists of various degrees, a neuropsychologist, 6 psychiatrists, and a psychiatric nurse practitioner (psych NP—the title used at that time). To be honest, I was clueless that this advanced nursing degree even existed. Having completed my psychiatry residency training 4 years earlier, and then working in the Worcester County area since that time, I had never crossed paths with a psych NP.

Initially I was skeptical and, frankly, put off by the fact this person was prescribing medications with relatively little formal training. With the overconfidence (or maybe insecurity) of my 12 years of training in biochemistry, medical school, internship, and psychiatry residency, it was hard for me to believe that the Commonwealth of Massachusetts would license a nurse with a few years of additional training to practice clinical psychiatry—and to prescribe medications no less! The 6 psychiatrists who had worked with this psych NP for years continually reassured me that the nurse was clinically solid and competent. Over time I came to the same conclusion. We became, and remain, colleagues. I now refer patients to her without any reservation.

Over the next 10 years I served as the supervising psychiatrist to 5 PMH-APRNs in various clinical settings in Newburyport, as a legal supervision contract was required by the Massachusetts Board of Registration in Nursing. For the first 5 years, I met with these PMH-APRNs weekly. After relocating to New Hampshire and shifting my practice to a community mental health center (CMHC) in 2007, my supervision transformed to a consultation role per the New Hampshire Board of Nursing requirements. I continue to thoroughly enjoy these consultation meetings, and I remain impressed with these individuals’ clinical skills, eagerness to learn, and commitment to improve their patients’ functioning.

In New Hampshire, PMH-APRNs fill a huge void by providing psychiatric treatment that otherwise would not exist. I know this from direct personal experience. There are 10 CMHCs in New Hampshire, and collectively they employ roughly equal numbers of PMH-APRNs and psychiatrists. At our CMHC, we have 9 psychiatrists and 4 PMH-APRNs. We have increased our access in the community by having these PMH-APRNs work in our community hospital’s emergency department, spend time at the local homeless shelter, and schedule onsite hours at nearby community health centers (CHCs). Additionally, the waiting time for an initial evaluation has decreased.

Similarly, throughout the United States, CHCs and CMHCs experience a disproportional shortage of psychiatric prescribers. Over the past 20 years, one growing resource has been the utilization of PMH-APRNs. In 2010, the American Psychiatric Nurses Association chose this new title and acronym to replace 2 older titles: psychiatric nurse practitioner and psychiatric clinical nurse specialist. For the interested reader, Mary D. Moller, DNP, ARNP, PMHCNS-BC, CPRP, FAAN, provides a historical review of the specialty of PMH-APRN from its beginnings at Rutgers University in 1954 to its current status.³

Currently, each state maintains its own licensing requirements and range of prescription privileges for PMH-APRNs. Yang et al reviewed the number of mental health-related visits at CHCs during the years 2006 through 2011 in states where nurse practitioners had “independent practice authority” (NP-IPA), as compared with states where they did not.⁴ Not surprisingly, in states with NP-IPA, there was a significant increase in mental health-related treatment/prescriptions by the NPs, which demonstrates increased utilization of NPs for mental health visits in CHCs. Most recently, in the January 2021 issue of Psychiatric Services, Frissora and Ranz from the Department of Psychiatry at Columbia University Medical Center in New York discuss how PMH-APRNs serve an important role in providing access to psychiatric treatment, especially in rural areas, urban neighborhoods, CHCs, and other settings with significant unmet mental health access. The authors describe their development of a federally qualified health center’s Community Psychiatry Nurse Practitioner Fellowship, and the success of this program.⁵

I have lectured in 47 states, including many rural and economically deprived areas. In all clinical settings, but especially these, the majority of frontline psychiatric treatment is delivered by PMH-APRNs. The local primary care physicians, clinics, and hospitals count on them. In my view, PMH-APRNs have become well-needed colleagues that are an integral part of our national health care system and allow us to fulfill our primary oath as physicians: “Do no harm.” There simply are not enough of us psychiatrists in the United States. Period. Engaging with PMH-APRNs as essential team members only serves to improve access and quality of treatment for all of our patients.

Let me be clear, PMH-APRNs do not have the depth of training or the clinical acumen equal to ours as trained and board-certified psychiatrists. In my experience, this should not negate the clinical knowledge and experience that they do offer, and the value they can bring to raising the level of psychiatric care to individuals experiencing mental illness.

Psychiatry is not the only field turning to this group to extend care. Most medical practices, hospitals, clinics, emergency rooms, walk-in acute care centers, CHCs, CMHCs, and other types of health care delivery utilize specialized APRNs as an integral part of their treatment teams. Two years ago, my mother’s health was rapidly declining from advanced congestive heart failure, which resulted from open heart surgery at age 39 at the Massachusetts General Hospital (MGH) in Boston. She remained a patient at MGH for 44 years after her open heart surgery. During the last year of her life, I would bring her intermittently to meet with her cardiology team at MGH, which included 3 different cardiology subspecialists. Significantly, for every 2 of her 3 monthly visits she was evaluated exclusively by a cardiac APRN. After my mom died, we sent flowers to this cardiac APRN in appreciation of her time, skill, and compassion for my mother.

Similarly, this past fall, for my routine 10-year screening colonoscopy, my anesthesia was managed by a nurse anesthetist. I had full confidence in her competence. Due to a health insurance policy change, I recently transferred my primary care to a local family practice physician. The practice consists of himself, a family APRN, and a physician’s assistant. My first appointment was with the APRN, and I left feeling good about my new health care team.

PMH-APRNs have become an integral part of health care in the United States. For us in psychiatry, I consider them an integral part of our treatment teams: psychiatrists, PMH-APRNs, psychiatric nurses, psychologists, neuropsychologists, pharmacists, therapists, case managers, occupational therapists, emergency service clinicians, students in training of all types, and more. What is important is that each professional member on Team Psychiatry knows what we each know, what we don’t know, and to seek out consultation as needed. Each of us has unique training, responsibilities, limitations, and value. Collectively we can rise to the challenge of providing quality mental health care in all treatment settings in the United States.

References

1. Thomas KC, Ellis AR, Konrad TR, Holzer CE, Morrissey JP. County-level estimates of mental health professional shortage in the United States. Psychiatr Serv. 2009;60:1323-1328.

2. Butryn T, Bryant L, Marchionni C, Sholevar F. The shortage of psychiatrists and other mental health providers: Causes, current state, and potential solutions. Int J Acad Med. 2017;3(1):5-9.

3. Moller MD. Advancing the role of advanced practice psychiatric nurses in today’s psychiatric workforce. Current Psychiatry. 2017;16(4):15-20.

4. Yang BK, Trinkoff AM, Zito JM, et al. Nurse practitioner independent practice authority and mental health service delivery in US community health centers. Psychiatr Serv. 2017;68(10):1032-1038.

5. Frissora KM, Ranz JM. A community psychiatry nurse practitioner fellowship: preparing nurse practitioners for mental health workforce expansion. Psychiatr Serv. 2021;72(1):91-93. ❒

^{This article was originally posted ahead of print on February 10, 2021, and has since been updated. -Ed}

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