In Reply: Grace and Christensen make an interesting contribution to the discussion of shortages by suggesting that physician assistants may be well positioned to provide needed additional mental health services. Their letter provides an opportunity to clarify the take-away messages presented in our recent workforce articles.
First, to clarify the role of physician assistants in our analyses, our estimates of mental health need were based on estimates of actual service use, which included any visits with physician assistants that could be identified as mental health visits. Our supply estimates excluded psychiatric physician assistants because, as Grace and Christensen point out, very few exist. Our shortage estimates were adjusted for the availability of primary care providers, including physician assistants, to account for the fact that some mental health services are provided in primary care settings.
Second, we do not argue for or against "demedicalizing psychiatric practice." We mentioned a variety of ways in which states have expanded services to meet mental health needs, including the extension of prescriptive authority to new professional groups. Our intention was to generate discussion about workforce shortages rather than to endorse any particular solution. Further, we agree that the safety of consumers is important. Any professional group taking on the role of mental health prescriber would require additional training and appropriate supervision.
Third, this discussion raises a broader set of issues that need to be considered in addressing mental health needs. Grace and Christensen touch on some of these issues. A key point is that training alone will not solve the problem, and there is no guarantee that new providers will practice in the public sector or in rural areas where the greatest shortages exist. We need to learn how to make practice in these areas both feasible and attractive to mental health professionals. Another point is that legal or political resistance to policy changes will surely come into play. However, maximizing the well-being of consumers should be an overriding concern in determining new mental health policies.
Finally, we want to emphasize that our recent workforce studies were based on current treatment patterns. The ways in which mental health services are currently organized and delivered in the United States, however, are not necessarily the best ways. What's needed, then, is a deeper discussion about financial organization, service system structure, and the appropriate balance among treatment modalities, including individual treatments such as medication, counseling, diet, and exercise as well as systemic interventions with families, wider social networks, and communities. Long-term mental health workforce development depends not only on producing sufficient numbers of qualified professionals but also on building satisfying work environments and using the best available strategies to help create meaningful outcomes for consumers.