To the Editor: In the October 2009 issue, Thomas and colleagues (1) documented the severe shortage of mental health practitioners who are prescribers in the United States and suggested several strategies to grow the prescriber workforce. One approach emphasized expanding the number of advanced practice psychiatric nurses. Another advocated extending prescribing privileges to psychologists. We found it curious that one group of midlevel providers, physician assistants, was not mentioned. We agree that increasing the number of midlevel prescribers is part of the solution to this critical unmet need. However, there are legitimate concerns about solutions that might endanger patient safety by demedicalizing psychiatric practice (2). Physician assistants who receive additional psychiatric training may provide a safe and cost-effective solution to this problem.
The number of physician assistant programs and graduates is expanding dramatically. During the relatively brief history of this profession, physician assistants have demonstrated a laudable record of providing primary health care services to rural and underserved communities. Physician assistants work under the supervision of physicians and have a history of successful collaborative partnerships with psychiatrists. Therefore, there may be much less political and legal resistance to expanding the number of psychiatric physician assistants than to granting prescriptive authority to other professional disciplines.
Although most physician assistants obtain postgraduate specialty training on the job, an increasing number of these medically trained providers pursue advanced training in formal year-long postgraduate fellowship programs. This specialty training seems particularly relevant because some of the clinical skills and knowledge required for mental health practice (for example, psychiatric interviewing and diagnosis, basic counseling skills, and knowledge of interpersonal dynamics) are not covered in depth during the general two-year physician assistant curriculum. Formal year-long physician assistant psychiatric training programs would enable new graduates to rapidly increase their competency to treat persons with mental illnesses, which might otherwise take many years of "on the job" experience. Unfortunately, there is a shortage of such programs. The Association of Postgraduate Physician Assistant Programs lists only two postgraduate programs in psychiatry (3).
We believe that dramatically increasing the number of psychiatric training programs for physician assistants may be an important step in developing a comprehensive mental health care workforce strategy designed to train prescribing professionals. Academic departments of psychiatry could take the lead in the development of these programs, with a primary focus on public and community psychiatry or treatment of persons with chronic mental illness so that graduates would be ready to serve in areas of greatest need. By drawing upon a department's PGY-1 psychiatry curriculum and modifying existing training resources, it is even conceivable that psychiatric physician assistant programs could be established relatively quickly.
Indeed, there is a paramount need for flexibility and creativity in crafting solutions to the desperate shortage of mental health care prescribers while maintaining a transdisciplinary commitment to patient safety. Searching for ways to increase the number of psychiatric physician assistant training programs may be an important, but seemingly overlooked, first step in achieving this critical balance.
Dr. Grace is affiliated with the North Florida-South Georgia Veterans Health System and with the Department of Clinical and Health Psychology, University of Florida, Gainesville. Dr. Christensen is with the Division of Public Psychiatry, University of Florida College of Medicine, and is director of behavioral health services at the Sulzbacher Center, Jacksonville.
1.Thomas KC, Ellis AR, Konrad TR, et al: County-level estimates of mental health professional shortage in the United States. Psychiatric Services 60:1323–1328, 20092.Freedman R: Matching patients and providers across the United States. Psychiatric Services 60:1293, 20093.APPAP Programs by Specialty. Philippi, Wyo, Association of Postgraduate Physician Assistant Programs, 2009. Available at www.appap.org/prog_specialty.html