What is the American Mental Health Crisis?

The US is experiencing an urgent mental health crisis. According to Mental Health America, “About one in five Americans experienced a mental illness from 2017 to 2018, and the pandemic has sparked even more feelings of anxiety, depression, and isolation. The rate of moderate to severe anxiety peaked in September 2020, with more than eight in 10 people showing moderate to severe symptoms in screenings for anxiety and depression.”

According to CDC, the number of visits to physician offices with mental disorders as the primary diagnosis in 2019 was 55.7 million.

Americans spending the amount of money on treating mental health illnesses far exceeds even that of cancer and heart disease. Spending on mental health treatment and services reached $225 billion in 2019, and depression alone is estimated to account for $44 billion in losses to workplace productivity. There is rising epidemiology of opioid addiction, suicide, drug overdose, and depression, which needs to be urgently addressed, and this is compounded by an ongoing opioid crisis in the US.

What is the opioid crisis?

There was a common misperception that prescription misuse was without risk because the drugs were legal and approved by regulating agencies. Due to the potential lethality of opioids by public health workers and emergency services, the need to exercise caution went unheeded. Due to the widespread prescription of opioid pain relievers in the late 1990s, there was an increase in addiction to opioids and subsequent misuse. These included prescription pain relievers, heroin, and synthetic drugs such as fentanyl.

The devastating consequences of rampant use were:

• 50,000 and more people died from opioid-involved overdoses in 2019
• 1.7 million people in the United States were suffering from substance use disorders related to prescription opioid pain relievers
• There were rising incidences of newborn children experiencing withdrawal syndrome due to opioid use and misuse during pregnancy
• Increase in injection drug use has also contributed to the spread of infectious diseases, including HIV and hepatitis C

The Acting Health and Human Services (HHS) Secretary in 2017 declared the opioid crisis is a nationwide public health emergency and revealed a 5-point strategy to fight this epidemic and invested $900 million in opioid-specific funding.

The 5-point strategy included:

• Improve access to prevention, treatment, and recovery support services
• Target the availability and distribution of overdose-reversing drugs
• Train first responders and strengthen public health data reporting and collection
• Support cutting-edge research on addiction and pain
• Advance the practice of pain management

How do we provide adequate mental health care?

More and more people are seeking professional help for their mental health problems. Many patients report their mental healthcare needs have not been met, and many reports that they cannot afford care. Today, more than one-third of the US population lives in areas where there are shortages of mental health professionals. This gap in mental health care has been due to the shortage of behavioral healthcare professionals such as psychiatrists and psychologists.

Compounding this is the primary care physician shortage as there are many more mental health visits at the primary healthcare level than at the specialty level. There is a national shortage of psychiatrists and primary care physicians, but a significant number of mental health professionals accept insurance, making high-quality care expensive for many people. An hour-long traditional therapy session can range from $65 to $250 for those without insurance. The CDC has reported the percentage of those reporting unmet mental health care needs increasing from 9.2% to 11.7%. Increases were most significant among adults aged 18–29 years and those with less than high school education.

Today, America faces an urgent need to provide high-quality and affordable care by qualified professionals. To tackle this crisis, it is necessary to increase the number of practicing mental health professionals and help existing one’s better deal with their caseloads.
One practical strategy to help address the growing demand for mental health services would be to increase the involvement of physician assistants, particularly in the primary care setting.

Who are physician assistants?

The physician assistant is a qualified medical professional who practices medicine collaboratively with a licensed physician. They exercise independent medical decision-making within their scope of practice.
They perform the following services in primary health care:

• Take the medical history of a patient
• Perform physical examination
• Order laboratory tests and diagnostics to study the extent of the illness
• Diagnose and prescribe medications to treat the illness
• Counsel patients and families
• Assist in surgery such as setting bones and stitching wounds
• Maintain the records of patients and provide the necessary documentation to insurance companies
• Research on the latest treatments
• Participate in outreach programs about managing disease and promoting wellness

What is the role of a physician assistant in this crisis?

There are around 140,000 certified physician associates in the United States, and 25% of them are working in primary care and 1.6% in psychiatry. Being in the frontline of the healthcare system, most physician assistants encounter behavioral conditions and mental health disorders regardless of the specialty they are working in. Though physician assistants in mental health practices evaluate patients with psychiatric symptoms most often, the physician associates working in general internal medicine, emergency medicine, family medicine, and hospital medicine also regularly come across mental health patients almost as frequently.

Benefits of the physician associate within the medical system:

• With physician assistants working across the United States and across all specialties, they are a human resource that can be easily tapped in to cater to the increasing mental healthcare needs of the population.
• As physician assistants follow the training model similar to physicians’, it is easy to streamline them into roles similar to physicians.’
• They have a generalist model of education that allows them to change specialties. They could be easily made to fit into roles that could cope and alleviate the growing demand for mental health services.
• It is also thought that the use of physician associates may reduce the costs of mental health services, thus leading to more people accessing care.
• Physician assistants work in underserved areas and provide critical health care functions in settings with fewer physicians, such as rural locations, small hospitals, and nonteaching hospitals. They can provide mental health services in these settings.

At the screening level, the patients with mental health illness that physician associates encountered most were for:

• Depression
• Bipolar Disorder
• Anxiety Disorder
• Substance Abuse Disorder
• Obsessive-Compulsive and Related Disorders
• Trauma-Related Disorders

The scope of work presented for the physician associates to treat such patients include :

• Address substance abuse
• Prescribe controlled medication
• Identify and manage medication misuse
• Identify addictive drugs 
• Prescribe buprenorphine for opioid addiction treatment

The rise of psychiatric and substance abuse disorders in the US has been a growing concern. Treatment of mental disorders is costly and out of reach of a significant portion of the population. This has led to increases in patient disability and premature mortality. Another important factor that has adds to this problem is the shortage of providers who care for patients with mental illness and long wait times to access care. With the mental health crisis growing bigger each day, US Healthcare is looking within its medical fraternity to address this need. One viable route would be to increase the involvement of physician assistants to address this problem. Physician assistants could be trained to perform in the psychiatric setting and could work with psychiatrists in a team-based approach to increase the number of people under the healthcare net and to give people care at lesser costs. Understanding the primary and specialty sides would be a valuable resource to deal with this problem.

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