Community Workers May Address Psychiatrist Shortage

A pilot project that trains lay community members to screen for and address common psychiatric disorders, addiction issues, and suicide risk promises to bring timely, evidence-based health services to those with little to no access to effective care.

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

Dr Milton Wainberg

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

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

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

Half of the United States population will be diagnosed with a mental or substance use disorder in their lifetime, but only about half of those will receive proper treatment. That percentage is even greater among lower-income groups and minorities, said Wainberg.

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 historic paradigm of ongoing long-term care is costly and not a feasible public mental health model. There is no evidence that it works and there is increasing demand for brief interventions,” said Wainberg.

The new initiative — called ENGAGE — has its origins in parts of Africa, where nurses had to be trained during the AIDS crisis as there weren’t enough doctors to roll out antiretroviral therapy.

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

The training involves a didactic component and an experiential component, in which trainees work with at least three cases under supervision to demonstrate competency. Technical assistance and other supports, such as refresher training, are offered for a year after training.

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

Those who do not require a referral are offered an intervention personalized to their need.

The training costs $5000 per person. “We calculated for New York State it would cost only $18 million to train everybody we need,” said Wainberg.

Cost Effective

He stressed the program, which is funded by the New York Office of Mental Health, is cost effective. Just like patients don’t need to see a plastic surgeon to have a small mole removed, they don’t always need to see a psychiatrist for run-of-the-mill mild depression, he said.

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

Wainberg has been inundated with interest in the initiative. “Over the last 3 months I have been having 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, sustainability, and cost. And he aims to expand the project beyond New York.

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

Unique Program

Commenting for Medscape Medical News, Jonathan 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 pilots that I know of in this country to train lay members of the community to screen for mental illness and substance use disorders and even to provide evidence-based treatment for people who may have more mild symptoms and might not yet need to see a professional, but otherwise would not have access to care.”

Alpert noted the current challenges of accessing care for a mental health or substance abuse disorder. “Many clinics have wait 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 treatments. “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.”

Although this pilot program will have to be assessed for effectiveness, “the concept behind it is very important,” said Alpert. “If you’re relying on MDs and PhDs to provide mental health services, there just aren’t enough of us to go around.”

Wainberg and Alpert report no relevant financial relationships.

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

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