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The need for mental health care around Macon is on the rise. Where are the psychiatrists?

Macon Telegraph - 8/19/2018

Aug. 19--Three of Macon's 20 board-certified psychiatrists have left the area in the past year, shrinking the already scarce supply of mental health providers in Middle Georgia.

With only 17 psychiatrists serving the more than 152,000 residents of Bibb County, that means there's about one psychiatrist for every 9,000 residents. That's not enough mental health providers to sufficiently serve its population, according to the Georgia Department of Community Health.

As of November 2017, portions of all but seven of Georgia's 159 counties were in the same situation.

Georgia ranked 34 out of 41 localities surveyed for availability of psychiatrists per capita, according to a 2018 study by the physician search firm Merritt Hawkins. Washington D.C., which topped the list, had about 29 psychiatrists for every 100,000 residents, while Georgia had fewer than seven.

The dearth of psychiatrists across the country isn't a new problem, said Richard Elliott, professor emeritus at Mercer University School of Medicine and a staff psychiatrist at River Edge Behavioral Health. Staffing shortages have been an issue since the early days of psychiatric institutionalization, when one psychiatrist was responsible for 1,800 patients, he said.

But Elliott said he first noticed a downturn in the early 1990s, when applications to psychiatry residencies started to decline. As the need for mental health care has increased over the years, the number of medical students going into psychiatry hasn't grown at the same rate, leaving many mentally ill patients without treatment.

As rates of suicide and mental health disorders rise nationwide, a shortage of psychiatrists could have grave consequences for the region.

'Psychiatry's kind of shot itself in the foot'

Multiple factors have contributed to the shortage of psychiatrists in the area, said psychiatrist Leslie Tomek, program director of Coliseum Health System's psychiatry residency.

Tomek said when she was in medical school in the late 1990s, many students chose to go into family medicine.

"I think a lot of people around my age, there's not as many psychiatrists, because there wasn't that really big push for mental health care," she said.

Psychiatrists are on average the third-oldest group of medical physicians, with nearly 60 percent of practicing psychiatrists 55 or older, according to the Merritt Hawkins report. As psychiatrists continue to age and retire, the problem could get worse.

Elliott said recent developments in the field that have changed how psychiatrists interact with patients might also have contributed to the shortage.

"I think psychiatry's kind of shot itself in the foot by moving away from the broadest view of understanding an individual both biologically and psychologically, and moved into, sort of, a very narrow view of: it's all about the brain," he said. "And it's an illusion that they can understand people by understanding the brain. You can't do that. And so, I think they missed, kind of, the part of psychiatry that's most appealing, the chance to understand people from multiple perspectives in depth and then use that understanding to try to help them."

Elliott said one of his favorite parts of his job is spending time with patients. But as movements to reduce stigma surrounding mental health disorders have gained momentum, he said psychiatry has started to spend less time getting to know patients and more time writing prescriptions.

"The drug companies have a lot to do with this. They've oversold so many diagnoses and oversold them as biological conditions," Elliott said. "But advocacy groups have done the same thing. In order to destigmatize psychiatric illness, they've oversold it as, 'These are medical illnesses, and it's all about the brain.' We're much more complicated than that."

Elliott doesn't disagree with the need to address mental illness as a biological condition or the importance of medication to treat patients. But he fears the shift away from quality face time with patients, especially the most vulnerable, might make it more difficult both to treat patients in a holistic way and attract new people to the field.

Many medical students don't want to work in jails, prisons and psychiatric institutions, where some of most seriously ill mental health patients require care, Elliott said.

"I think we have to work to take students out into those areas and say, 'Look at this. Here are the poorest, the sickest, the neediest patients. ... They need your help and helping them with these mental health conditions, with poverty and housing,' " he said. "And people don't go to medical school to learn about those things. They don't see that as real medicine. So it leads to psychiatry becoming kind of not really one of the important specialties."

'They're getting sicker'

Low reimbursement rates from insurance companies, Medicare and Medicaid also make it difficult for psychiatrists to make money if they go into private practice, which has contributed to the scarcity of outpatient psychiatrists in Macon, Tomek said. And she added that the shortage affects residents throughout Middle Georgia, because there are few psychiatrists in the area outside of Bibb County.

As the need for treatment continues to exceed the number of providers, wait lists continue to grow. Both Tomek and Elliott said it can take months for an appointment slot to open up with one of Macon's psychiatrists. And that wait can have serious consequences for people seeking help.

Tomek said societal attitudes toward mental health often make it difficult for patients to come forward and accept they need treatment. When a psychiatrist isn't immediately available, she said that makes it even more difficult for patients to get care.

Without access to preventive care, those suffering from mental health disorders are more likely to wait until they need emergency treatment.

"If you have lack of outpatient psychiatrists -- so, community psychiatrists -- people are still going to have mental health problems, and then they're not getting care," she said. "And when that occurs, then a lot of the patients are getting -- they have untreated symptoms. They're getting sicker, and they're receiving care in the ER instead."

Better access to outpatient care would reduce the cost of treatment, said Jason Hobbs, a licensed clinical social worker at Middle Georgia Counseling and Testing in Centerville. The shortage of psychiatrists often forces patients to seek expensive treatment at the emergency room, which can take a financial toll on patients, especially those who are uninsured.

Unmanaged mental health disorders can also affect physical health, Hobbs said.

"Many things are related to the amount of anxiety someone experiences," he said. "We see higher instances of, you know, obesity. We see higher instances of immunological issues, inflammatory illnesses, autoimmune disorders."

Elliott said lack of psychiatric care is also linked to higher mortality rates, partly due to an increased risk of suicide.

"People who are -- have serious, persistent mental illnesses, that's the technical name for it -- tend to drift downward in society," he said. "They tend to be less affluent. As they become poorer, more likely to be homeless, they begin to acquire debilitating physical conditions -- infections and lung disease and drug abuse. And so they end up having shorter lifespans, often times by 10 or 20 years."

But untreated mental illness can impact more than just the individual -- it can also affect the community at large. Hobbs said it's particularly difficult for children and adolescents in the area to access mental health care, which could have serious implications.

"I don't want to say that guns are not an issue. I do believe that guns are an issue. But the mental health of our children and adolescents, if they're not able to access services, well, that is certainly part of the issue of safety in our schools," Hobbs said. "So, you know, if the community wants to consider that part of the problem -- not all of the problem, but part of the problem -- that's certainly something to attend to."

Elliott said research has shown better psychiatric care could also have a positive economic effect.

"You can save taxpayer dollars if you treat people effectively in the community," he said. "That takes psychiatry, more than other specialists."

More access to psychiatric treatment can benefit the general public, as well.

"The individuals' lives will be a lot better, but you'll also reduce some of the overpopulation in jails and prisons and other institutions," Elliott said. "We could help a lot of people, and they would be better at their, you know, their relationships, their jobs, function better in the community."

Looking to the future

Psychiatrists are not the only mental health care providers in the area. Therapists and social workers like Hobbs also provide counseling to those in need, and research suggests therapy can be just as effective as medication in some cases. But without a medical degree, they can't prescribe medication and aren't always equipped to deal with more severe mental health disorders or crisis situations.

There's only one way to overcome the local shortage of psychiatric care: recruit more psychiatrists.

As the need for mental health care providers has grown in recent years, psychiatry residencies across the country have started to fill up, Tomek said.

"Psychiatry is becoming very competitive, and a lot more medical students are choosing psychiatry as their career," she said.

In July 2016, Coliseum Health System launched its psychiatric residency program, which it hopes will bring new psychiatrists to the area. There are now eight residents -- four in their first year and four in their second. The four-year residency program will graduate four new psychiatrists each year, starting in 2020.

Tomek hopes some of the residents will practice in Macon once they graduate.

"They have definitely expressed interest," she said. "I think once they get here and they start learning about the Macon community, I think people develop roots and want to stay."

Samantha Max is a Report for America corps member and reports for The Telegraph with support from the News/CoLab at Arizona State University. Follow her on Facebook at facebook.com/samantha.max.9 and on Twitter @samanthaellimax. Learn more about Report for America at www.reportforamerica.org.

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(c)2018 The Macon Telegraph (Macon, Ga.)

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