The number of psychiatric prescribers per capita is at one of the lowest levels in history.1 Approximately 43.4 million persons (17.9%) in the United States have a diagnosable mental illness2; 9.8 million (4%) are diagnosed with a serious and persistent mental illness, such as schizophrenia, bipolar disorder, and major depressive disorder (these figures do not include substance use disorders).3
Of the 45,000 licensed psychiatrists, approximately 25,000 are in active practice.4 By comparison, there are approximately 19,000 practicing licensed psychiatric advanced practice registered nurses (APRNs).5 Annually, approximately 1,300 physicians graduate from psychiatric residency programs6 and 700 APRNs from master’s or Doctor of Nursing Practice programs.7 Combining the 2 prescribing workforces (44,000) yields a ratio of 986 patients per licensed prescriber. Seeing each patient only once every 2 months would equate to 25 patients daily considering a 5-day work week. Recognizing that some patients need much more frequent follow-up, this is an impossible task even if these providers and patients were dispersed uniformly across the United States. Currently, ratios are calculated based on the number of psychiatrists per 100,000 individuals, which in the United States is 16.8 Most psychiatrists practice in urban areas,9 whereas psychiatric nurse practitioners are found primarily in rural and less populated urban areas.10
Who can provide care?
Although the growing number of psychiatric APRNs is encouraging for the mental health workforce, their limited role and function remain a battle in the 27 states that do not grant full practice authority. This dispute has become so contentious that the Federal Trade Commission (FTC) has stated that the debate over scope of practice represents federal restraint of trade,11 while patients and their families suffer from lack of access to care.
Recognizing that 9 million patients age <65 who were enrolled in Medicaid in 2011 and treated for a mental health disorder (20% of enrollees) accounted for 50% of all Medicaid expenditures prompts the question, “Who is treating these patients?” According to the American Academy of Nurse Practitioners, 75% of nurse practitioners accept and treat both Medicaid and Medicare patients compared with 43% of psychiatrists who accepted Medicaid and 54% who accepted Medicare in 2011 (these numbers do not include potential overlap).12
Who are APRNs?
The first master’s degree in nursing was created by Hildegard Peplau, EdD, at Rutgers University in 1954, using the title Clinical Specialist in Psychiatric Mental Health Nursing (PMH-CNS). As a master’s prepared clinician, the PMH-CNS could function independently, and many chose to open private practices. Other universities began to create clinical specialty programs in a variety of disciplines. In 1996, 41 states granted prescriptive authority to the PMH-CNS. Psychiatric nurse practitioners were first certified in 2000 to meet the statutory requirements for prescriptive authority of the other 9 states. However this created 4 PMH-APRN roles: Adult and Child/Adolescent CNS and Adult and Family PMHNPs.
Clinical specialists in most areas of health care—except for psychiatry—were primarily working in institutional settings, whereas nurse practitioners were hired principally in primary care community-based settings. The public grew familiar with the term “nurse practitioner,” but these professionals functioned primarily under institutional protocols, while the PMH-CNS had the ability to practice independently. In the mid-1990s, the 4 advanced practice nursing roles of nurse midwife, nurse anesthetist, nurse practitioner, and clinical nurse specialist were encompassed under 1 title: APRN. In 2010 the American Psychiatric Nurses Association endorsed one title for the psychiatric mental health advanced practice registered nurse (PMH-APRN), the psychiatric nurse practitioner, to be educated across the lifespan.
Today, the title PMH-APRN encompasses both the PMHNP and PMH-CNS; the majority specialize in the adult population.