Building The Mental Health Workforce Capacity Needed To Treat Adults With Serious Mental Illnesses

Serious mental illnesses, such as major depressive disorder, bipolar disorder, and schizophrenia, are leading causes of medical burden in the United States. ¹ Yet approximately one-third of the roughly ten million Americans with such illnesses receive no mental health treatment. ² Moreover, many who receive services obtain inadequate care, ³ and service gaps have increased in recent years. According to one analysis, the number of Americans who reported needing but not receiving mental health care increased by approximately two-thirds between 1997 and 2010. ⁴

Several factors contribute to delays and difficulties in accessing mental health services. The barriers are complex and rooted in deep biological, economic, social, attitudinal, historical, and geographic factors that affect objective and perceived need for care and the supply of mental health providers. On the provider side, workforce planning is hindered by a scarcity of information concerning the size, composition, distribution, and patient care activities of the provider workforce. Working within existing knowledge constraints, increasing demand for mental health services places pressure on public policy makers to improve access to mental health services.

The Affordable Care Act (ACA), together with legislation extending mental health parity coverage, is increasing demand for a wide range of mental health services including services for patients with serious mental illnesses. In one early evaluation, Medicaid coverage of patients with psychotic disorders seen in emergency department settings more than doubled following Medicaid expansion under the ACA. ⁵ In addition to broadened Medicaid eligibility in participating states, increased demand for mental health services might be driven by other factors such as the inclusion of mental health benefits as essential covered services in private insurance plans; subsidies for low- and middle-income people to purchase insurance; penalties for not having health insurance; and protections for insurance access for people with preexisting mental health conditions. ⁶

In this context, this article provides an overview of the current adequacy of the mental health workforce to treat adults with serious mental illnesses in the United States. I provide a summary of factors contributing to the geographic maldistribution of psychiatrists and psychologists, the relatively low proportion of mental health professionals treating patients with serious mental illnesses, and potential benefits and limitations of relocating treatment of patients with serious mental illness to primary care settings. To help fill gaps in care, I present policy recommendations to address the financing, training, and organization of mental health professionals.

Challenges Of Accessing Mental Health Care

Unmet need for mental health care is concentrated among people who are working age, are lower income, reside in rural areas, and lack health insurance. ^3,4 Because unmet need for mental health care is approximately five times greater for uninsured than privately insured people, ⁴ increases in the number of people with insurance brought about by the ACA ⁷ have placed new strains on mental health professionals.

Access to mental health care is often difficult. Long periods commonly elapse between the onset of a psychiatric disorder and the delivery of an effective treatment. During this period, substantial deterioration can occur in the affected person’s functioning, which can complicate recovery. ⁸ In major depressive disorders, for example, although 90 percent of affected individuals eventually receive treatment, the average time from disorder onset to first treatment is approximately eight years. ⁹ Substance abuse is associated with even longer lags in treatment. ⁹

Mental health problems first commonly present in general medical settings. Approximately two-thirds of primary care physicians, however, report that they cannot secure a mental health referral for their patients with mental health problems. ¹⁰ Difficulties accessing specialty mental health services force primary care providers to deliver more mental health care. Between 1995 and 2010, per capita outpatient medical visits to primary care physicians for treatment of depression and bipolar disorder increased significantly faster than per capita outpatient medical visits to psychiatrists. ¹¹ These trends, which reflect widespread problems with access to specialty mental health services, contrast with broader trends toward specialization in US medical practice. ¹²

Psychologists And Psychiatrists

Psychologists and psychiatrists are the most highly trained professionals in the mental health workforce, and psychologists greatly outnumber psychiatrists. The number of active doctoral-level psychologists remained essentially constant from 83,258 in 2008 to 83,142 in 2013, although on a per capita basis they declined from 1 per 3,652 people in 2008 to 1 per 3,802 people in 2013. ¹³ During this same period, the number of active psychiatrists in the United States decreased from 38,857 in 2008 to 37,296 in 2013 or from 1 per 7,825 people to 1 per 8,476 people. ^14,15 With 56.7 percent of psychiatrists at least age fifty-five, they are also the third-oldest in age of those in the medical specialties. ¹⁴ In addition to psychiatrists and doctoral-level psychologists, there are approximately 75,000 master’s-trained psychologists ¹³ and 168,000 mental health counselors and marriage and family therapists in the United States. ¹⁶

Because becoming a psychiatrist or psychologist requires a long period of training, increasing the number of training positions is unlikely to have a major short-term impact on workforce shortages. Although there have been modest increases in the number of first-year psychiatric residency training positions ¹⁷ and clinical psychologist internship matches in recent years, ¹⁸ expanding training slots entails long time lags and high costs. It is also unlikely to substantially improve the geographic maldistribution of mental health professionals or increase the number who participate in the Medicaid program.

The national shortage of psychiatrists and psychologists is exacerbated by geographic maldistribution. Both types of professionals tend to aggregate in urban instead of rural areas. Across the states, the number of psychiatrists per capita varies almost fivefold from rural states such as Idaho (5.2 per 100,000 people) to more urban states such as Massachusetts (24.7 per 100,000), and the number of psychologists varies almost tenfold from 7.9 per 100,000 people in Mississippi to 76.0 per 100,000 in Massachusetts. ² On the basis of population and number of mental health professionals, rural counties in the middle of the country, especially on the eastern side of the Rocky Mountains, are the most underserved. ¹⁹ Shortages in rural areas might help account for the lower rates of mental health treatment among adults with mental disorders in rural areas than among their counterparts who live closer to metropolitan areas. ³ Although primary care and mental health telemedicine might be sufficient for people in rural settings who have less serious mental health problems, adults with serious mental illnesses often need more intensive services that are delivered directly by mental health specialists.

Scholarships and loan repayment programs have had some success in recruiting and retaining mental health professionals to underserved areas. The National Health Service Corps (NHSC) loan repayment program, which offers financial incentives to attract health care professionals to underserved areas, ²⁰ is the largest such public program. State repayment programs also play an important role, especially for physicians. ²¹ The NHSC was initially devoted to assisting primary care physicians and dentists. Over the past several years, though, the program has broadened to mental health professionals including psychiatrists, psychologists, psychiatric nurse practitioners, and licensed clinical social workers. A 2012 study found that four years after completing their NHSC service commitment, 61.1 percent of mental health care professionals continued to practice in underserved areas. ²²

The NHSC has rapidly expanded in recent years. Between 2009 and 2011, the number of participating mental health clinicians, not including psychiatrists, more than doubled. By 2011, 27 percent ( $n=2,111$ ) of the total NHSC workforce consisted of mental health clinicians, excluding psychiatrists. ²³ The NHSC is expected to continue to grow with additional appropriations through the ACA.

The NHSC loan repayment program is available only to US citizens. One policy option involves relaxing the NHSC citizenship requirement and allowing participating health facilities in underserved areas that are unable to fill positions with US citizens to employ qualified immigrants as mental health professionals and waive the return-home requirement under the J-1 visa program (which requires visa holders to return to their home countries for at least two years at the end of their visitor programs). Expanding efforts to import psychiatrists and other mental health professionals from other countries could help address regional shortages. In addition, the use of such professionals might help narrow gaps in service access for adults with serious mental illnesses. Compared with psychiatrists who are US medical graduates, those who are international medical graduates—many of whom are immigrants—work longer hours, treat a higher proportion of patients with serious mental illnesses, and more often accept Medicaid-financed patients. ²⁴

Although admittedly challenging in the current political climate, such an expansion of the NHSC would have a precedent in broader efforts to expand opportunities for immigrants offered by the long-standing pilot Conrad 30 Waiver program. That program issues waivers for the two-year home-residence requirement for foreign medical graduates with J-1 visas who practice for at least three years in full-time employment at health care facilities in designated shortage areas. ²⁵ However, even modest proposals to expand the pilot waiver program have encountered political opposition. ²⁶

Increasing the range of mental health care facilities that are eligible to become NHSC clinical sites might further expand opportunities for participating mental health professionals to treat patients with serious mental illnesses. At present, community mental health centers are the only mental health specialty settings that are eligible to become NHSC-approved sites. ²⁷ If facilities meet all other NHSC requirements, consideration should be given to permitting state and county mental hospitals, freestanding mental health clinics, and other facilities that serve patients with serious mental illnesses to participate in the NHSC.

Although several patient factors—such as stigma, lack of knowledge about mental health problems and treatments, and limited insight into the need for treatment—often cause people to delay seeking treatment, shortages of mental health clinicians also play an important role. In addition, relatively few psychologists and psychiatrists are extensively engaged in the care of adults with serious mental illnesses.

In a typical month, approximately four of ten psychologists do not serve any patients with a serious mental illness, and those who do serve such patients treat an average of only ten each month. ²⁸ This might partially reflect the orientation of many training programs toward careers working with people with less serious conditions. In one survey, only about half of clinical psychology graduate programs offered coursework focused on patients with serious mental illnesses. ²⁹ Doctoral students in clinical psychology also tend to feel less comfortable treating patients with schizophrenia than treating patients with less severe conditions. ³⁰

Although psychiatrists tend to be more involved than psychologists in treating patients with serious mental illnesses, ^31,32 there is considerable variation in the extent to which psychiatrists treat these patients. In one national survey, for example, 23.5 percent of practicing psychiatrists reported treating three or fewer patients with schizophrenia each month. ³³ A dearth of recent information on practice patterns, especially those of psychiatrists, complicates planning efforts to identify and address workforce shortages to care for high-need populations.

Financial barriers might compound lack of service access for patients with serious mental illnesses. Medicaid, which is the largest source of mental health care financing in the United States, plays a pivotal role in financing the care of such patients. Approximately two-thirds of Americans with schizophrenia are enrolled in Medicaid. ³⁴ However, psychiatrists are much less likely than most other medical specialists to accept Medicaid. In 2009–10 the Medicaid acceptance rate for office-based psychiatrists was 43 percent, compared with 73 percent for all other specialists. Among physician specialties, only dermatologists had a lower Medicaid acceptance rate than psychiatrists. ³⁵ In addition, relatively few psychologists participate in Medicaid (32 percent). Low rates of provider participation in Medicaid significantly constrain treatment access for adults with serious mental illnesses. This translates into large caseloads for those professionals who do participate and long wait lines for Medicaid patients seeking intake appointments followed by short and infrequent visits.

Psychologists ³⁶ and psychiatrists ³⁷ commonly cite low reimbursement rates as a reason for not participating in the Medicaid program. For medical services, Medicaid pays, on average, only 53 percent of the rate that commercial insurance pays. ³⁸ Additionally, Medicaid fee schedules generally do not distinguish between doctoral-level psychologists and master’s-level counselors. ³⁹ One possible but expensive policy option to encourage greater Medicaid participation by psychiatrists and psychologists is to raise Medicaid reimbursement rates to match those offered by private insurance plans. Because delays in reimbursement and administrative hassles are also cited as barriers to providers’ Medicaid participation, ⁴⁰ higher reimbursement rates might be more successful if coupled with a faster and simpler reimbursement process than is now in use.

To be sure, it is also unclear how attractive higher Medicaid reimbursement rates would be to psychiatrists. The broader trend in office-based psychiatric practice is away from even private insurance. In recent years, a smaller percentage of office-based psychiatrists accepted private insurance (55 percent) than other physician specialists (89 percent), and the rate declined faster for psychiatry than for other medical specialties. ³⁵ Because more than half of office-based psychiatrists are in solo practice, they might also lack the business infrastructure to negotiate with third-party payers. ⁴⁰

Shortages place psychiatrists them in a strong market position and provide them with little incentive to accept Medicaid or private insurance. Shortages also likely contribute to psychiatrists’ opting to practice in affluent urban and suburban areas. By contrast, adults with serious mental illnesses are concentrated in low-income communities. Low family income predisposes to the onset of mood, anxiety, and substance use disorders, ⁴¹ while schizophrenia and other psychotic disorders are associated with marked declines in socioeconomic status. ⁴² Unless there are substantial increases in the workforce of psychiatrists and psychologists together with reforms that financially favor caring for low-income patients, market forces will limit the number the psychiatrists and psychologists who elect to practice in poorer communities and who rely primarily on Medicaid reimbursement.

Social Workers

Clinical social workers outnumber doctoral-level psychologists and psychiatrists combined. There are nearly 200,000 clinical social workers in the United States. ⁴³ Approximately 57,000 of them serve in outpatient care settings; another 70,000 work in hospitals; ⁴⁴ and the remainder work in mental health centers, social agencies, private practice, and other settings. Approximately 11,000 work specifically in mental health clinics and outpatient facilities. ⁴⁵ Within mental health care, the scope of social work practice generally includes diagnosing mental disorders; providing psychosocial treatments to individuals, families, and groups; and coordinating care.

Social workers are well positioned to help meet shortages in the mental health workforce in treating adults with serious mental illnesses. Their large numbers and their knowledge of community social services are important assets. Adults with serious mental illnesses often need services outside of the health care system. For example, they may need assistance with rehabilitative, housing, employment, and social and child welfare services and support in their interactions with the criminal justice system. Additionally, social workers often possess the requisite skills for coordinating the complex service needs of adults with serious mental illnesses.

To support a greater engagement of social workers in the direct clinical care of patients with serious mental illnesses, however, investment will be necessary in continuing education in relevant evidence-based clinical practices. Some of the most well-established, evidence-based psychosocial interventions for adults with serious mental illnesses—including assertive community treatment, family psychoeducation, and strengths-based case management—are grounded in social work. Expanding primary and continuing social work education in these and other related interventions would help prepare social workers to work with psychiatrists and other therapists in treating adults with serious mental illnesses.

Delivering clinical care to adults with serious mental illnesses tends to lower job satisfaction and raise burnout among social workers, ⁴⁶ perhaps even more than among other mental health professionals. ⁴⁷ As a result, providing social workers with adequate support, training, and financial compensation will be important to the long-term success of initiatives aimed at increasing their role in managing the care of adults with serious mental illnesses.

At the individual level, promising strategies to reduce staff burnout include teaching cognitive behavioral stress reduction and coping, social support enhancement, and mindfulness skills. Corresponding organizational interventions include improving the clarity and accuracy of job descriptions, training supervisors to provide positive social support, and creating shared values and a positive work culture. ⁴⁸

Mainstreaming Mental Health Care

Another option for addressing gaps in service access for people with serious mental illnesses is to shift more of their care to a team-based approach in the general medical sector. In such collaborative care models, mental health specialists serve more in a consulting than a direct service role. Care managers, who might be nurses, clinical social workers, or licensed psychologists with appropriate training, monitor symptoms and advise patients on self-management, while primary care providers maintain primary responsibility for patient care. Collaborative care makes efficient use of psychiatrists and psychologists by enabling them to focus on decision support and patients whose clinical complexity might otherwise exceed the competence of primary care clinicians.

Over the past several years an impressive body of research has developed in support of the effectiveness of collaborative care in primary care for treating depression and anxiety disorders. ⁴⁹ Some of the most persuasive results have been achieved with older depressed patients. In one study, older adults who were treated in primary care practices with additional mental health resources to manage their depression had a lower risk of mortality than comparable patients receiving usual care without access to the collaborative care team. ⁵⁰ Beyond clinical trials, there are examples of well-functioning integrated behavioral health care services within primary care service organizations. ⁵¹ However, chronic care models for depression have proved difficult to implement in many primary care settings. ⁵²

Organizational changes encouraged by the ACA, including patient-centered medical homes, accountable care organizations, and health homes, have promoted integration of mental health services into primary care. ⁵³ Yet few of these models are equipped to meet the complex service needs of adults with the most serious mental illnesses that cross mental health, rehabilitative, occupational, housing, and social welfare domains. Disappointing results of clinical trials that have attempted to extend collaborative care models to more serious psychiatric disorders have revealed the limits of primary care–centered team management approaches for patients with complex mental health service needs. ^54,55

Few primary care practices—even those that have developed close collaborative relationships with mental health professionals—have the resources to provide the intensive coordinated ongoing outreach necessary for the successful care of people with the most serious mental illnesses. Many primary care physicians are not comfortable treating patients with more serious mental illnesses, ⁵⁶ and it is difficult to achieve optimal mental health treatment of these patients in primary care settings with psychiatrists or psychologists in supporting or consultative roles. ⁵⁵

By increasing the efficiency of psychiatric services for patients who present with complex or treatment-resistant mood and anxiety disorders, collaborative care can nevertheless help reduce regional shortages of mental health specialists. In contrast, patients with psychotic disorders and severe mood disorders are likely to benefit from higher levels of involvement with mental health specialists than primary care–based collaborative care models typically provide. An alternative model involves integrating basic primary care services into specialty mental health clinics for adults with serious mental illnesses. ⁵⁷ In Missouri, the Medicaid Health Home provision of the ACA has been used to support community mental health center–based health homes. In this model, nurse care managers and primary care physicians consult with community mental health centers. They assess adults with serious mental illnesses for medical problems and then implement individualized treatment plans through referral for follow-up medical services. ⁵⁸

Policy Recommendations

Although coverage for mental health services has expanded and more people use these services than ever before, critical gaps persist, even among adults with serious mental illnesses. This article has offered four policy recommendations, each of which addresses different aspects of this challenge: expanding federal and state loan repayment programs for mental health professionals to practice in underserved areas; increasing public reimbursement to health care professionals for treating patients with serious mental illnesses; training social workers in relevant evidence-based psychosocial interventions; and building team-based mental health services in primary care.

Yet it is unreasonable to expect that these recommendations, even if fully implemented, would repair the long-standing maldistribution of mental health specialists. Nevertheless, concerted policy efforts can ameliorate shortages in the number and distribution of mental health professionals who are dedicated to the care of adults with serious mental illnesses.

ACKNOWLEDGMENTS

This article was supported by Grant No. U19 HS021112 from the Agency for Healthcare Research and Quality and by the New York State Psychiatric Institute.

NOTES

• 1 Whiteford HA , Degenhardt L , Rehm J , Baxter AJ , Ferrari AJ , Erskine HE , et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010 . Lancet . 2013 ; 382 ( 9904 ): 1575 – 86 . Crossref, Medline, Google Scholar
• 2 Substance Abuse and Mental Health Services Administration . Behavioral health barometer: United States, 2014 . Rockville (MD) : SAMHSA ; 2015 . (Department of Health and Human Services Publication No. SMA-15-4895). Google Scholar
• 3 Wang PS , Lane M , Olfson M , Pincus HA , Wells KB , Kessler RC . Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication . Arch Gen Psychiatry . 2005 ; 62 ( 6 ): 629 – 40 . Crossref, Medline, Google Scholar
• 4 Roll JM , Kennedy J , Tran M , Howell D . Disparities in unmet need for mental health services in the United States, 1997–2010 . Psychiatr Serv . 2013 ; 64 ( 1 ): 80 – 2 . Crossref, Medline, Google Scholar
• 5 Schaper EC , Murphy DL , Wirshing WC . Early evidence of the Affordable Care Act’s impact on medically indigent population consuming emergency mental health care in Los Angeles County . Am J Psychiatry . 2014 ; 171 ( 10 ): 1117 . Crossref, Medline, Google Scholar
• 6 Garfield RL , Zuvekas SH , Lave JR , Donohue JM . The impact of national health care reform on adults with severe mental disorders . Am J Psychiatry . 2011 ; 168 ( 5 ): 486 – 94 . Crossref, Medline, Google Scholar
• 7 Pear R . Number of uninsured has declined by 15 million since 2013, administration says . New York Times [serial on the Internet]. 2015 Aug 12 [cited 2016 Apr 4 ]. Available from: http://www.nytimes.com/2015/08/12/us/number-of-uninsured-has-declined-by-15-million-since-2013-administration-says.html Google Scholar
• 8 Perkins DO , Gu H , Boteva K , Lieberman JA . Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: a critical review and meta-analysis . Am J Psychiatry . 2005 ; 162 ( 10 ): 1785 – 804 . Crossref, Medline, Google Scholar
• 9 Wang PS , Berglund P , Olfson M , Pincus HA , Wells KB , Kessler RC . Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication . Arch Gen Psychiatry . 2005 ; 62 ( 6 ): 603 – 13 . Crossref, Medline, Google Scholar
• 10 Cunningham PJ . Beyond parity: primary care physicians’ perspectives on access to mental health care . Health Aff (Millwood) . 2009 ; 28 ( 3 ): w490 – 501 . DOI: 10.1377/hlthaff.28.3.w490 Go to the article, Google Scholar
• 11 Olfson M , Kroenke K , Wang S , Blanco C . Trends in the office-based mental health care provided by psychiatrists and primary care physicians . J Clin Psychiatry . 2014 ; 75 ( 3 ): 247 – 53 . Crossref, Medline, Google Scholar
• 12 Barnett ML , Song Z , Landon BE . Trends in physician referrals in the United States, 1999–2009 . Arch Intern Med . 2012 ; 172 ( 2 ): 163 – 70 . Crossref, Medline, Google Scholar
• 13 Lin L , Nigrinis A , Christidis P , Stamm K . Demographics of the U.S. psychology workforce: findings from the American Community Survey [Internet]. Washington (DC) : American Psychological Association ; 2015 Jul [cited 2016 Apr 4 ]. Available from: http://www.apa.org/workforce/publications/13-dem-acs/report.pdf Google Scholar
• 14 Association of American Medical Colleges, Center for Workforce Studies . 2014 physician specialty data book [Internet]. Washington (DC) : AAMC ; 2014 Nov [last updated 2015 Jun 3; cited 2016 Apr 4 ]. Available from: https://members.aamc.org/eweb/upload/Physician%20Specialty%20Databook%202014.pdf Google Scholar
• 15 Association of American Medical Colleges . Diversity in the physician workforce: facts and figures 2010 [Internet]. Washington (DC) : AAMC ; 2010 [cited 2016 Apr 4 ]. Available from: https://www.aamc.org/download/432976/data/factsandfigures2010.pdf Google Scholar
• 16 Department of Labor, Bureau of Labor Statistics . Mental health counselors and marriage and family therapists [Internet]. Washington (DC) : BLS ; 2015 Dec 17 [cited 2016 Apr 4 ]. Available from: http://www.bls.gov/ooh/community-and-social-service/mental-health-counselors-and-marriage-and-family-therapists.htm Google Scholar
• 17 Association of American Medical Colleges . Electronic residency application service data [Internet]. Washington (DC) : AAMC ; 2015 Dec 15 . Table C-4, Residency applicants from US MD—granting medical schools by specialty, 2010–2011 through 2015–2016; [cited 2016 Apr 22 ]. Available from: https://www.aamc.org/download/321564/data/factstablec4.pdf Google Scholar
• 18 Association of Psychology Postdoctoral and Internship Centers . Match statistics 1999, 2010 [Internet]. Houston (TX) : APPIC ; [cited 2016 Apr 4 ]. Available from: http://www.appic.org/Match/Match-Statistics Google Scholar
• 19 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 ( 10 ): 1323 – 8 . Crossref, Medline, Google Scholar
• 20 National Health Service Corps . Loan Repayment Program [Internet]. Washington (DC) : Department of Health and Human Services ; [cited 2016 Apr 4 ]. Available from: http://nhsc.hrsa.gov/loanrepayment/eligibility.html Google Scholar
• 21 Pathman DE , Goldberg L , Konrad TR , Morgan JC . State repayment programs for health care education loans . JAMA . 2013 ; 310 ( 18 ): 1982 – 4 . Crossref, Medline, Google Scholar
• 22 National Health Service Corps . NHSC clinician retention: a story of dedication and commitment [Internet]. Washington (DC) : Department of Health and Human Services ; 2012 Dec [cited 2016 Apr 4 ]. Available from: https://nhsc.hrsa.gov/currentmembers/membersites/retainproviders/retentionbrief.pdf Google Scholar
• 23 Pathman DE , Konrad TR . Growth and changes in the National Health Service Corps (NHSC) workforce with the American Recovery and Reinvestment Act . J Am Board Fam Med . 2012 ; 25 ( 5 ): 723 – 33 . Crossref, Medline, Google Scholar
• 24 Blanco C , Carvalho C , Olfson M , Finnerty M , Pincus HA . Practice patterns of international and U.S. medical graduate psychiatrists . Am J Psychiatry . 1999 ; 156 ( 3 ): 445 – 50 . Medline, Google Scholar
• 25 Kahn TR , Hagopain A , Johnson K . Retention of J-1 visa waiver program physicians in Washington State’s health professional shortage areas . Acad Med . 2010 ; 85 ( 4 ): 614 – 21 . Crossref, Medline, Google Scholar
• 26 Kennedy E , Specter A . Amendment to Comprehensive Immigration Reform Act of 2007 . S.Amdt.1150 to S.1348. Google Scholar
• 27 Health Resources and Services Administration, Bureau of Health Workforce . National Health Service Corps site reference guide [Internet]. Rockville (MD) : HRSA ; 2016 Mar [cited 2016 Apr 4 ]. Available from: http://nhsc.hrsa.gov/downloads/sitereference.pdf Google Scholar
• 28 Michalski D , Mulvey T , Kohout J . 2008: APA survey of psychology health service providers [Internet]. Washington (DC) : American Psychological Association ; 2010 May [cited 2016 Apr 4 ]. Available from: http://www.apa.org/workforce/publications/08-hsp/index.aspx Google Scholar
• 29 Millet PE , Schwebel AI . Assessment of training received by psychology graduate students in the area of chronic mental illness . Prof Psychol Res Pr . 1994 ; 25 ( 1 ): 76 – 9 . Crossref, Google Scholar
• 30 Buck B , Romeo KH , Olbert CM , Penn DL . Self-reported comfort treating severe mental illnesses among pre-doctoral graduate students in clinical psychology . J Ment Health . 2014 ; 23 ( 6 ): 297 – 302 . Crossref, Medline, Google Scholar
• 31 Pingitore DP , Scheffler RM , Stentell T , West JC . Comparison of psychiatrists and psychologists in clinical practice . Psychiatr Serv . 2002 ; 53 ( 8 ): 977 – 83 . Crossref, Medline, Google Scholar
• 32 Norcross JC , Karpiak CP , Santoro SO . Clinical psychologists across the years: the division of clinical psychology from 1960 to 2003 . J Clin Psychol . 2005 ; 61 ( 12 ): 1467 – 83 . Crossref, Medline, Google Scholar
• 33 Olfson M , Marcus SC , Wilk J , West JC . Awareness of illness and nonadherence to antipsychotic medications among persons with schizophrenia . Psychiatr Serv . 2006 ; 57 ( 2 ): 205 – 11 . Crossref, Medline, Google Scholar
• 34 Khaykin E , Eaton WW , Ford DE , Anthony CB , Daumit GL . Health insurance coverage among persons with schizophrenia in the United States . Psychiatr Serv . 2010 ; 61 ( 8 ): 830 – 4 . Crossref, Medline, Google Scholar
• 35 Bishop TF , Press MJ , Keyhani S , Pincus HA . Acceptance of insurance by psychiatrists and the implications for access to mental health care . JAMA Psychiatry . 2014 ; 71 ( 2 ): 176 – 81 . Crossref, Medline, Google Scholar
• 36 Michalski DS , Kohout JL . The state of the psychology health service provider workforce . Am Psychol . 2011 ; 66 ( 9 ): 825 – 34 Crossref, Medline, Google Scholar
• 37 Long SK . Physician may need more than higher reimbursements to expand Medicaid participation: findings from Washington State . Health Aff (Millwood) . 2013 ; 32 ( 9 ): 1560 – 7 . Go to the article, Google Scholar
• 38 Fox W , Pickering J . Hospital and physician cost shift: payment level comparison of Medicare, Medicaid, and commercial payers [Internet]. Seattle (WA) : Milliman ; 2008 Dec [cited 2016 Apr 4 ]. Available for download from: http://us.milliman.com/common/wireframes/Search.aspx?q=Hospital%20%26%20physician%20cost%20shift Google Scholar
• 39 Roe D , Yanos PT , Lysaker PH . Overcoming barriers to increase the contribution of clinical psychologists to work with persons with severe mental illness . Clin Psychol (New York) . 2006 ; 13 ( 4 ): 376 – 83 . Medline, Google Scholar
• 40 Cummings JR . Rates of psychiatrists’ participation in health insurance networks . JAMA . 2015 ; 313 ( 2 ): 190 – 1 . Crossref, Medline, Google Scholar
• 41 Sareen J , Afifi TO , McMillan KA , Asmundson GJ . Relationship between household income and mental disorders: findings from a population-based longitudinal study . Arch Gen Psychiatry . 2011 ; 68 ( 4 ): 419 – 27 . Crossref, Medline, Google Scholar
• 42 Aro S , Aro H , Keskimäki I . Socio-economic mobility among patients with schizophrenia or major affective disorder. A 17-year retrospective follow-up . Br J Psychiatry . 1995 ; 166 ( 6 ): 759 – 67 . Crossref, Medline, Google Scholar
• 43 Substance Abuse and Mental Health Services Administration . Behavioral health, United States, 2012 . Rockville (MD) : SAMHSA ; 2013 . (Department of Health and Human Services Publication No. SMA 13-4797). Google Scholar
• 44 Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis . The U.S. health workforce chartbook: part IV: behavioral and allied health [Internet]. Washington (DC) : HRSA ; 2013 Nov [cited 2016 Apr 4 ]. Available from: http://bhpr.hrsa.gov/healthworkforce/supplydemand/usworkforce/chartbook/chartbookpart4.pdf Google Scholar
• 45 National Association of Social Workers, Center for Workforce Studies and Social Work Practice . Social workers in mental health clinics and outpatient facilities: occupational profile [Internet]. Washington (DC) : NASW ; 2011 [cited 2016 Apr 4 ]. Available from: http://workforce.socialworkers.org/studies/profiles/Mental%20Health%20Clinics.pdf Google Scholar
• 46 Acker GM . The impact of clients’ mental illness on social workers’ job satisfaction and burnout . Health Soc Work . 1999 ; 24 ( 2 ): 112 – 9 . Crossref, Medline, Google Scholar
• 47 Priebe S , Fakhoury WK , Hoffman K , Powell RA . Morale and job perception of community mental health professionals in Berlin and London . Soc Psychiatry Psychiatr Epidemiol . 2005 ; 40 ( 3 ): 223 – 32 . Crossref, Medline, Google Scholar
• 48 Morse G , Salyers MP , Rollins AL , Monroe-DeVita M , Pfahler C . Burnout in mental health services: a review of the problem and its remediation . Adm Policy Ment Health . 2012 : 39 ( 5 ): 341 – 52 . Crossref, Medline, Google Scholar
• 49 Woltmann E , Grogan-Kaylor A , Perron B , Georges H , Kilbourne AM , Bauer MS . Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: systematic review and meta-analysis . Am J Psychiatry . 2012 ; 169 ( 8 ): 790 – 804 . Crossref, Medline, Google Scholar
• 50 Gallo JJ , Morales KH , Boner HR , Raue PJ , Zee J , Bruce ML , et al. Long term effect of depression care management on mortality in older adults: follow-up of cluster randomized clinical trial in primary care . BMJ . 2013 ; 346 : f2570 . Crossref, Medline, Google Scholar
• 51 Cohen DJ , Davis MM , Hall JD , Gilchrist EC , Miller BF . A guidebook of professional practices for behavioral health and primary care integration: observations from exemplary sites . Rockville (MD) : Agency for Healthcare Research and Quality ; 2015 Mar . (AHRQ Publication No. 14-0070-1-EF). Google Scholar
• 52 Zafar W , Mojtabai R . Chronic disease management for depression in US medical practices: results from the Health Tracking Physician Survey . Med Care . 2011 ; 49 ( 7 ): 634 – 40 . Crossref, Medline, Google Scholar
• 53 Mechanic D , Olfson M . The relevance of the Affordable Care Act for improving mental health care . Ann Rev Clin Psychol . 2016 ; 12 : 515 – 42 . Crossref, Medline, Google Scholar
• 54 Saitz R , Cheng DM , Winter M , Kim TW , Meli SM , Allensworth-Davies D , et al. Chronic care management for dependence on alcohol and other drugs: the AHEAD randomized trial . JAMA . 2013 ; 310 ( 11 ): 1156 – 67 . Crossref, Medline, Google Scholar
• 55 Schnurr PP , Friedman MJ , Oxman TE , Dietrich AJ , Smith MW , Shiner B , et al. RESPECT-PTSD: re-engineering systems for the primary care treatment of PTSD, a randomized controlled trial . J Gen Intern Med . 2013 ; 28 ( 1 ): 32 – 40 . Crossref, Medline, Google Scholar
• 56 Sansone RA , McDonald S , Prutzman C , Henkaline TC . The comfort level of internists with the prescription of psychotropic medication . Int J Psychiatry Med . 2006 ; 36 ( 1 ): 85 – 92 . Crossref, Medline, Google Scholar
• 57 Scharf DM , Eberhart NK , Hackbarth NS , Horvitz-Lennon M , Beckam R , Han B , et al. Evaluation of the SAMHSA primary and behavioral health care integration (PBHCI) grant program: final report (task 13) [Internet]. Santa Monica (CA) : RAND Corporation ; 2014 [cited 2016 Apr 4 ]. Available from: http://www.rand.org/content/dam/rand/pubs/research_reports/RR500/RR546/RAND_RR546.pdf Google Scholar
• 58 SAMHSA-HRSA Center for Integrated Health Solutions . Population management in community mental health center-based health homes [Internet]. Washington (DC) : SAMHSA-HRSA Center for Integrated Health Solutions ; 2014 Sep [cited 2016 Apr 4 ]. Available from: http://www.integration.samhsa.gov/integrated-care-models/14_Population_Management_v3.pdf Google Scholar