The US faces a shortage of mental healthcare practitioners; consequently, patients are working with mental health nurse practitioners (MHNPs) and PAs in increasing numbers.
Each type of provider has a different scope of practice and may be limited in what and how they can prescribe.
Clinicians can familiarize themselves with this trend and learn how to navigate these emerging care navigation dynamics.
The US healthcare system is in the midst of a serious mental healthcare provider shortage. According to the Kaiser Family Foundation, the US was only meeting 27.2% of its total mental healthcare need as of September 2022.
This gap is particularly acute for psychiatrists. Research published in Psychiatric Services predicted that the US will see a shortage of between 14,280 to 31,109 psychiatrists by 2024. Closing this gap are mental health nurse practitioners (MHNPs) and PAs.
What does this shift in provider delivery mean for the future of mental healthcare?
Assessing the MHNP, PA trend
The move toward NPs and PAs predates the COVID-19 pandemic. A September 2022 Health Affairs research article studied the trend between 2011 and 2019.
Researchers examined a 100% sample of Medicare claims for fee-for-service beneficiaries with an average age of 61. These patients saw MHNPs or psychiatrists.
The researchers found that overall, the two types of practitioners saw the same types of patients, provided similar services, and even wrote similar prescriptions. But this is where the similarities end.
During the study period, the number of MHNPs treating Medicare recipients increased by 162%. The data indicated a downturn of 6% among psychiatrist-patient encounters. The total annual number of mental health office visits for every 100 recipients dropped from 27.4 to 24.2 (11.5%). This stemmed from a 29% decline in psychiatric visits, bolstered by an 111.3% increase in MHNP visits.
Ultimately, 12.5% of 2011 mental health visits were with MHNPs. That figure climbed to 29.8% in 2019. In rural areas with a full scope of practice, more than 50% of mental health visits were with MHNPs.
"[Psychiatric mental health nurse practitioners] are a rapidly growing workforce that may be instrumental in improving mental health care access."
— Cai et al., Health Affairs
Understanding the scope of practice
How will this rapidly growing workforce reshape mental healthcare? Understanding stems from comparing the scope of practice for MHNPs, PAs, and psychiatrists.
MHNPs typically hold a master’s or doctorate degree in nursing, along with 2 years of work experience. The average annual salary for NPs is $114,510, according to Nurse Journal. They assess and diagnose patients, as well as treat their conditions with psychotherapy, counseling, and medication, which they can prescribe.
They also may educate patients and families, providing resources. MHNPs have an optional psychiatric-mental health nurse practitioner certification but must hold a valid state NP license. MHNPs are more likely to work in mental health clinics or hospitals.
Psychiatrists hold an MD or a DO and complete 4 years of residency in a psychiatric program. Their scope of practice is similar to that of MHNPs.
Psychiatrists, who earn an average annual salary of $217,100, must have board certification from the American Board of Psychiatry and Neurology, as well as a valid state license. Private practice is the setting for over 50% of psychiatrists, although many also work in places similar to MHNPs.
PAs specializing in psychiatric/mental health practice under a psychiatrist’s supervision. The scope of practice for psychiatric PAs is similar to that of psychiatrists and MHNPs, including assessment, diagnosis, creating treatment plans, and prescribing. They also work in similar practice settings.
The average PA earns $121,530 per year, according to the US Bureau of Labor Statistics. PAs have a master’s degree. Programs last about 26 months and are accredited by the Accreditation Review Commission on Education for the Physician Assistant.
Who can prescribe what?
While psychiatrists, MHNPs, and PAs can all prescribe, how and what they prescribe often differs from state to state. MDs and DOs have the highest level of prescriptive authority, which includes controlled substances.
PAs can prescribe but must do so with physician supervision.
The nature and extent of that supervision vary depending on the state in which the PA practices. States may also limit what a PA can prescribe.
NPs tend to have more prescriptive capacity than PAs and do not need to practice under physician supervision. However, some states do not allow NPs to prescribe controlled substances.
According to a 2022 StatPearls update, it’s likely that prescriptive authority will continue to expand for advanced practice providers such as PAs and NPs.
"Creating a dialogue between physician groups and advanced practice provider organizations can improve understanding of the attitudes towards increasing autonomy."
— Zhang, et al., StatPearls
“Interprofessional communication between different provider groups can enhance team performance while reducing polarizing beliefs,” the authors added.
A call for collaboration
That’s precisely what Amanda Zeglis, DO, a practicing psychiatrist and member of the MDLinx advisory board, recommends. She said that given the state of the mental health crisis, the trend of non-physician mental health support is here to stay—at least for the short term. Communication and collaboration are essential for successful patient outcomes.
“There can be complex cases or difficult circumstances whereby having a physician provider can be helpful,” Dr. Zeglis said. “However, providers have varying levels of education and experience, regardless of title or degree.”
"[It's] more important to identify our strengths and weaknesses as providers, regardless of our degree, such that we know when to reach out for help if we feel circumstances are beyond our abilities."
— Amanda Zeglis, DO
What this means for you
It’s possible (if not probable) that the number of MHNPs and PAs seeing patients for their mental healthcare needs will increase in the years ahead. While this is undeniably good for improving access to care, it does change the overall mental healthcare landscape. Optimal patient outcomes will require clinician collaboration and communication that accounts for different strengths and clinical experiences.