MENTAL HEALTH

Community workers may face a shortage of psychiatrists

A pilot project training lay community members to screen for and resolve common psychiatric disorders, addiction problems and suicide risk promises to offer timely, evidence-based health services to those with little or no access to effective treatment.

The current shortage of mental health physicians is driven by increased demand from a population more willing to seek psychiatric help and by physicians leaving the workforce. Both factors have been exacerbated by the COVID-19 pandemic.



Dr. Milton Wainberg

“It would be expensive to address the problem through additional specialized training, and doing so would take decades to see any changes,” said project leader Milton L. Wainberg, MD, professor of clinical psychiatry at Columbia University/New York State Psychiatric Institute . Medscape Medical News.

A better solution is to train community members to be the entry point into the mental health care system, a strategy that has proven effective.

Details of the project were discussed at the 2023 American Psychiatric Association (APA) Annual Meeting, held this week in San Francisco.

Half of the US population will be diagnosed with a mental or substance use disorder in their lifetime, but only about half of them will receive adequate treatment. That percentage is even higher among low-income groups and minorities, Wainberg said.

Despite the availability of multiple evidence-based therapies, there has been no reduction in the global prevalence of psychiatric illness since 1990, the first time this burden was determined, he said.

Unfeasible model

“The ongoing historical long-term care paradigm is expensive and not a viable public mental health model. There is no evidence that it works and there is a growing demand for brief interventions,” Wainberg said.

The new initiative called ENGAGE has its origins in parts of Africa where nurses needed to be trained during the AIDS crisis because there were not enough doctors to roll out antiretroviral therapy.

In the United States, the program trains and certifies community workers who are passionate about their community. “Community members want to learn how to help their neighbors,” Wainberg said. “When we give them the opportunity to learn skills that can actually change community members’ symptoms, they are thrilled.”

The training has a didactic component and an experiential component, where trainees work with at least three supervised cases to demonstrate proficiency. Technical assistance and other supports, such as refresher training, are offered for one year after the training.

Workers ask three initial questions to quickly determine if a person has a mental health disorder. Asking 10 additional questions tells the worker whether the person has a common mental disorder such as depression, anxiety, or post-traumatic stress disorder (PTSD), a substance use disorder involving alcohol or drugs, or risk of suicide, or a severe requiring referral to a mental health specialist.

Those who do not request a referral are offered a personalized intervention based on their needs.

The training costs $5,000 per person. “We calculated that it would cost New York State only $18 million to train everyone we need,” Wainberg said.

Cheap

He stressed that the program, funded by the New York City Bureau of Mental Health, is affordable. Just as patients don’t need to see a plastic surgeon to remove a small mole, they don’t always need to see a psychiatrist for ordinary mild depression, she said.

To date, 20 workers have been trained and started meeting clients in clinics in four boroughs/boroughs of New York City (Harlem, Brooklyn, Bronx and Washington Heights). Additional clinics in West Harlem and Staten Island are expected to begin training soon.

Wainberg was inundated with interest in the initiative. “Over the past 3 months I have had 15 meetings a day” with parties interested in getting more information or wanting to know how to start such a program.

He plans to examine the program’s effectiveness in a number of areas, including patient symptoms, timeliness of services, access, affordability and cost. And it aims to expand the project beyond New York.

Mental health specialists shouldn’t worry about becoming irrelevant with the addition of community workers, since the demand is so great, Wainberg said. “There will always be a need for the kind of care mental health specialists are trained to provide. This initiative aims to expand the capacity of those with less severe symptoms, who may not need an intensive level of intervention.”

Unique program

Commenting for Medscape Medical NewsJonathan E. Alpert, MD, PhD, chair of the Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center and Albert Einstein College of Medicine, New York City, said the project is “unique” and an “excellent” idea.

“This is one of the first pilot projects I know of in this country to train lay community members to screen for mental illness and substance use disorders and even to provide evidence-based treatment for people who may have milder symptoms And they might not even need to see a professional, but otherwise they wouldn’t have access to care.”

Alpert noted the current challenges in accessing care for a mental health or substance abuse disorder. “Many clinics have waiting lists of 3 to 6 months.”

Another issue is the “stigma and lack of trust” among minority communities when it comes to formal mental health treatment. “Having lay members who know the community, who look like the community, who understand the community, and who are available for screening and treatment is exceptionally important.”

While this pilot program will need to be evaluated for effectiveness, “the concept behind it is very important,” Alpert said. “If you’re relying on doctors and PhDs to deliver mental health services, we’re simply not enough to go around.”

Wainberg and Alpert report no material financial dealings.

2023 American Psychiatric Association (APA) Annual Meeting. Presented on May 21, 2023.

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