COVID-19 spurred a broad adoption of tele-medicine. Forced by circumstance at the beginning of the pandemic, patients, providers, policymakers and even financial markets became enthusiastic adopters of healthcare by video appointment. While many specialties have since reverted to in-person care, tele-medicine is likely to prove a lasting change in the field of psychiatry.
Of all medical specialties, psychiatry is best placed to take full advantage of tele-medicine. Unlike most medical specialists, psychiatrists typically don't require an in-person physical exam to diagnose and treat disorders. This allows them and their patients to take full advantage of tele-medicine's benefits.
At Apraku Psychiatry, all appointments take place by secure video; we see five core benefits of this approach for patients:
Research confirms that tele-psychiatry is effective and increases access to care. While tele-psychiatry obviously increases access at the population level, some may feel that it is an inferior substitute for in-person treatment. However, recent studies show that there is no compromise: outcomes are comparable to those observed in more traditional settings. The only exception may be patients with acute presentations who require additional support or a higher level of care. To read more about the evidence base for tele-psychiatry, check out this, this and this.
Therapy Through Art
When we think of "therapy", we tend to visualize talk sessions with a qualified therapist. Sitting on the proverbial couch, we spend hours exploring past experiences and learning new tools to deal with future challenges, possibly armed with a fast-depleting box of tissues.
But the concept of therapy is much broader. Ever put on a favorite song and feel comforted by its familiar notes? Then you already use music as therapy. If we only learn to appreciate them in the right way, a wider gamut of art - including literature and the visual arts - can also provide solace.
Art is therapeutic when it chimes with our inner selves. That favorite song you play has resonance because it recalls deeper insights that can too often be crowded out by intrusive, anxious thought. In highfalutin terms, it speaks the language of your soul. To elicit the benefits of art as therapy, we need only bootstrap our soul's vocabulary. In that spirit, let's explore three works of art that recall important insights when viewed in the right way.
Insight #1: Life is messy, and that's OK. Great anxiety arises from the many conflicting demands on our energy, all of which seem at once extremely important and yet stubbornly irresolvable. The ensuing aggregate stress stands in contrast to our dim recollection of a more peaceful childhood, when the most vexing dilemma might have been which flavor ice cream we desire on a hot summer's day. Stoic philosophy flips this anxious thought on its head: the aberration is not our present-day pickle, but instead the impossible simplicity of the child's bubble-wrapped world. That insight is strangely comforting, because it reminds us not to be shocked or dismayed when reality turns out to be rather more bitter than plain-vanilla; it was naive to imagine that things could ever have been otherwise. Art can remind us of this stoic insight. Entitled "Mixed up model", the painting below is composed by the mysterious Proudfoot brothers from New York. The defaced image mirrors the colorful complexity of our present reality. Life's journey is a unique chance to explore, understand and ultimately accept that messy complexity.
Insight #2: Even if you're alone, you're not alone. Another therapeutic function of art is to serve as a companion to our woe. Ironically, the artistic portrayal of cognitive frailty can be uplifting, because it reveals that our own troubles are not some faulty aberration of nature: they are instead a reassuringly common feature of the human condition. The painting below is taken from a series of works by British artist James Green, wryly termed "self-portraits of somebody else". It hauntingly depicts confusion and even torment; yet by witnessing these sensations externally our own confusion and torment is shared and therefore lessened.
Insight #3: Beauty is in the little things. The therapeutic value of art lies not just in projections of complex realities and shared suffering. Art also serves to remind us of beauty in the little things; those things too often overlooked in the frenetic 21st-century. Born in Wisconsin, the feminist icon Georgia O'Keeffe pioneered modernist art in the United States with abstract impressions of nature. In the painting below, she invites us to admire the understated elegance and bold color of a single lily. That a simple thing can convey such depth of beauty is an enduring source of hope.
Care to share? The richness of art is that every piece has therapeutic value by serving as a reminder of some deep insight. We'd love to hear your own stories of therapy through art, so why not send us a message with some favorite art of your own? If you'd like to read more about art as therapy, check out the book by John Armstrong and Alain de Botton (link), which popularized the idea of viewing art this way.
Finding a Good Psychiatrist
So you've decided to see a psychiatrist. Good on you - that's a big step towards getting better. Take a moment to congratulate yourself.
But where are the psychiatrists? Unfortunately, there is a growing shortage of psychiatrists in the United States. Demand for psychiatric services is increasing, partly due to greater awareness of mental health's importance, but the psychiatrist population - currently about 35,000 nationwide - is actually falling slightly as older providers retire (see post). That's a big social problem - and it also presents a challenge for the individual seeking good care.
Seek, and you shall find. The national shortage of psychiatrists means that you might need to put a little extra effort into finding the right provider for you. The first step is to figure out the right clinical setting. If the concern is urgent, an emergency room or urgent care clinic is most appropriate. In most cases, however, an out-patient clinic is the way to go. Cost-conscious patients can try to seek care from a local community clinic or find a provider who is in-network with their insurance carrier. Unfortunately, however, the availability of such providers is limited. Psychiatrists who accept insurance may also be more time-constrained as they typically see more patients per day.
Here's a handy stepwise guide for finding the right out-patient provider:
Trivializing Mental Illness
"Does that make me crazy?" Thus ask the soul duo Gnarls Barkley in the crescendo of their pop hit, "Crazy". Singer CeeLo Green then answers his own refrain: "Possibly". It's a groovy tune, but a responsible psychiatrist - maybe after showing off a few dance moves - should retort: "No, it doesn't. And by asking the question, you're trivializing mental illness."
Such language trivializes mental illness by minimizing its consequences. In the song, CeeLo Green rhetorically asks whether he is "crazy" because he "knew too much" and was "out of touch". This misuse of the word "crazy" is perpetuated in casual language, where it can refer to anything that deviates from middle-of-the-road conventionality. This definition creep - the origin of the word crazy is in something diseased, sickly, or broken - risks trivializing genuine mental illness.
Similar trivializations of mental illness in casual language are rife. Here are a few more examples that crop up in day-to-day speech:
Being mindful about our choice of words is not a form of censorship. Freedom of speech is important and should be protected, but it comes with responsibility. We are not entering some Orwellian dystopia by being more aware of how language shapes impressions of mental illness. Instead, the hope is that - with greater mindfulness in our choice of words - maladies of the brain will eventually come to be treated in society with the same level of seriousness as maladies afflicting other organs. Once we've achieved that level of collective enlightenment, we can reward ourselves with a celebratory dance to Gnarls Barkley's groovy tune. Just be mindful of the lyrics!
Health insurance companies maintain networks of medical providers, which offer services at pre-negotiated rates. These networks promise predictability in expenses for the insurance company, but limit choice for patients and can constrain access to effective health care.
Patient choice is hampered when networks are small. While insurance companies advertise impressively long lists of providers who are in-network, some of these providers may have long waiting lists or be closed to new patients. Even worse, they may have ceased their relationship with the insurance company or stopped practicing altogether. The latter case is what's known as a "ghost network" of providers nominally listed as in-network, but who are not in fact available to provide in-network services.
Ghost networks are particularly widespread in behavioral health. In two recent studies (see here and here) run by J. Wesley Boyd, a professor of psychiatry at Harvard Medical School, researchers contacted several hundred psychiatrists listed by Blue Cross Blue Shield as in-network providers. Of these, only about one-quarter were actually accepting new adult patients. Three-quarters were "ghosts" - either unreachable or not accepting new patients.
Insurance companies should be required to actively maintain lists of in-network providers. Inflating networks by not removing unavailable providers exaggerates the benefits of an insurance policy and misleads patients regarding their access to care. Fortunately, state authorities in California and Massachusetts have taken action against certain insurance companies that fail this basic duty. The hope is that this issue grows in salience as a matter of national importance.
The United States has a severe and growing shortage of psychiatrists. The Department of Health and Human Services estimates the shortage at between 5,500 and 9,000 psychiatrists as of 2016. By 2030, this shortage is expected to grow to between 13,680 and 17,430 psychiatrists, due to rising demand as well as a shrinking pool of psychiatrists (graduating residents are too few to replace new retirees).
Unfortunately, the current situation is perhaps even worse than described by the DHHS. For starters, the DHHS assumes that all psychiatrists work until age 75, which seems overly optimistic about enthusiasm for late-life work. Moreover, the DHHS report uses a dataset maintained by the American Medical Association, which records physicians' self-designated primary specialty. However, self-designation does not necessarily mean that a physician has expertise in psychiatry. Finally, AMA records are often not kept up to date by physicians, as this is not required for licensing purposes.
To better gauge the availability of qualified psychiatrists, we can use data from the American Board of Psychiatry and Neurology. Active certification by the ABPN is the gold standard in psychiatry. We further restrict the data sample to Board-certified psychiatrists who were initially certified between 1988 and 2019 (psychiatrists certified before 1988 are assumed to have retired, consistent with a retirement age of 65).
The ABPN data indicate that there are just over 35,000 Board-certified psychiatrists of working age in the US. This stands in contrast with the figure of approximately 45,000 estimated by the DHHS, suggesting that the current shortfall in psychiatrists may be twice as large as previously reported. Most of the discrepancy (about 8,000) arises from DHHS's assumed retirement age of 75 rather than 65, while the remainder (2.000) comes from the fact that the DHHS relies on physicians' self-designated specialty, rather than their Board certification.
The ABPN data also contain information on the primary city in which psychiatrists practice. This allows for in-depth analysis of geographic dispersion in availability. As a first step, we can plot the state-level distribution of psychiatrists per 100,000 population (see graph below). According to the DHHS, demand for psychiatric services requires a supply of approximately 15 psychiatrists per 100,000 population. Just six states - MA, RI, VT, CT, NY, MD (in descending order) - comfortably exceed this threshold; the vast majority of US residents therefore live in a state in which the psychiatrist-population ratio is inadequate according to DHHS estimates. Worryingly, 14 states have a psychiatrist-population ratio which is less than half of that which the DHHS deems adequate.
What can society do about this psychiatry shortage? To answer this question, it is important to distinguish two aspects of the problem: aggregate shortage and geographic dispersion.
To address aggregate shortage, there is only one answer: train more psychiatrists! Over the long run, an expansion in residency training programs would help to increase the rate at which retiring psychiatrists are replaced. In the shorter-run, a more liberal immigration policy and licensing regime with respect to foreign-trained psychiatrists would help to alleviate scarcity. These solutions are preferable to lowering standards of care, for example by expanding the ability of nurse practitioners to practice independently.
There are multiple solutions to the geographic dispersion problem. The most readily implementable involves greater adoption of tele-medicine, which can alleviate within-state scarcity. Unfortunately, state-level regulation of physician licensing impairs the ability of tele-medicine to alleviate cross-state scarcity, although the Interstate Medical Licensure Compact may be somewhat helpful in reducing frictions in this respect. In the longer-run, a strategic geographic reallocation of psychiatry residency programs could help to expand coverage in under-served areas. Some provisions in the Affordable Care Act (2010) went in this direction, but the analysis shown here underscores the need for a more extensive overhaul.
Massachusetts has the most psychiatrists per capita among US states. There are approximately 1,700 Board-certified psychiatrists of working age whose primary practice location is in Massachusetts. This gives the state 25 psychiatrists per 100,000 population - more than double the national average of 11.
Yet psychiatrists in the Bay State are heavily concentrated around Boston. About two-thirds are based within the I-95. Consequently, Massachusetts residents living outside of this bubble are less well served than the state-level average would suggest.
The map below plots the psychiatrist-population ratio at zipcode level. In addition to many rural communities, the city of Springfield in central Massachusetts, as well as Haverhill, Lawrence and Lowell in the north-east, are relatively poorly served, with psychiatrist-population ratios below the level deemed adequate by the Department of Health and Human Services. Across Massachusetts, nearly two million people live in a zipcode with a below-adequate psychiatrist-population ratio.
Thus, Massachusetts' number-one ranking among states should not be cause for complacency regarding the provision of mental health services. To alleviate local shortages, a more widespread use of tele-psychiatry can be effective in granting local populations access to out-of-town psychiatrists licensed in the state. In this way, tele-psychiatry can grant all Massachusetts residents the benefits of the state's relatively ample supply of psychiatrists - not just those who happen to live in the Boston area.
Becoming a Psychiatrist
The path to becoming a psychiatrist is long, requiring more than a decade in higher education. It starts with an undergraduate degree in which prospective psychiatrists often follow a "pre-med" sequence of courses that includes biology, chemistry, physics and math. Then comes medical school, which is a four-year journey comprising classroom learning, several day-long exams and a series of clinical rotations providing practical exposure to medical specialties.
After setting their sights on psychiatry, a freshly minted medical doctor must obtain admission to an accredited residency program. There are approximately 250 such programs in the United States. These four-year programs combine on-the-job training with specialized teaching in psychiatric science by professors in psychiatry. Upon graduating from such a program, physicians will have gained experience across the full range of psychiatric practice, from in-patient settings featuring patients with acute mental disorders to out-patient clinics in the community or college campuses.
Finally, after at least 12 years of intensive study and clinical practice, a would-be psychiatrist's training culminates in an eight-hour examination. Set by the American Board of Psychiatry and Neurology, this exam covers the full range of subject matter that psychiatrists are expected to master. Only after passing this exam can a physician claim to be Board-certified in psychiatry. The ABPN certifies about 1,500 new psychiatrists each year. This is actually slightly less than the number of psychiatrists retiring each year, which is why the United States faces a growing psychiatrist shortage.