UNDERSTANDING THE SHORTAGE OF PSYCHIATRISTS AND SELECTED OTHER

MENTAL HEALTH PROFESSIONALS IN ALABAMA

1. OVERVIEW:
The psychiatric manpower needs of Alabama have been significantly under scrutinized over the
last decade. Alabama has two potential sources of psychiatrists; in-state trainees, and out-of-
state recruits. The University of Alabama at Birmingham and the University of South Alabama
(USA) have each experienced difficulties in training the maximum number of psychiatrists;
many of whom may remain in Alabama. The University of South Alabama suffered from
management issues and the program at UAB suffered from a shortage of funding to support the
maximum number of candidates.

Statistics provided by the Substance Abuse and Mental Health Services Administration
(SAMHSA) and other federal agencies determine that Alabama has 7.1 practicing psychiatrists
per hundred thousand persons with the southeast region demonstrating a ratio of 8.2 as compared
to the New England region which demonstrates ratio of 26.9. The statistical methodology used
to determine the number of psychiatrists for “adequate” mental health care depends upon the
modeling system that is employed for the calculation i.e., usual care verses managed care (See
Table 1 and 2). Managed care systems would require a minimum ratio of 2.8 per hundred
thousand while customary care would require 12.2 per hundred thousand. The customary care
model does not account for increasing sophistication of treatment and future refinements of care
that require more physician time. Conversely, telemedicine and other interventions may reduce
physician time. The managed care model is not driven by physician care but rather by the use of
para-professionals and other non-physician healthcare providers to reduce cost of more
expensive interventions such as face to face psychiatric care. Managed care systems do not
consider financial burdens associated with commitment to state hospitals, incarceration in jail,
disruption of school environment, or any other social impact produced by diminished access to
physicians. In Alabama, some managed care physicians routinely commit “covered” individuals
to state hospitals where “free” services are provided because the managed care system will not
pay for services provided on “committed” patients.

Alabama has enjoyed considerable success in recruiting excellent international medical graduate
(IMG) physicians using the H1B and the J1 visa process. The national political support for this
process is diminishing and the access to visas is becoming more restrictive. Many international
medical graduates are recruited from countries where the World Health Organization has
identified massive mental health manpower shortages. The dependence on foreign medical
graduates to meet the mental health needs of Alabama and the United States does not produce a
genuine and acceptable solution to this problem.

2. RECRUITMENT OF PSYCHIATRISTS TO ALABAMA:

The ability to recruit psychiatrists into Alabama depends upon several factors to include (1)
availability of jobs (2) availability of psychiatric inpatients beds, and (3) ability of physicians to
obtain licensing in Alabama. The total number of inpatient psychiatric beds in Alabama has been
difficult to determine over the past decade; however, stake-holders concur that the total number
of inpatient beds has declined while the need for community-based beds has increased. The
issue of available beds remains highly controversial. Patients in South Alabama are routinely
admitted to hospitals in Pensacola. Psychiatrists are more likely to settle in areas where high
quality inpatient services are available. The medical licensing procedure in Alabama is one of
UNDERSTANDING THE SHORTAGE OF PSYCHIATRISTS IN ALABAMA
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the most restrictive in the nation. Alabama appears to be in the bottom third for flexibility of
licensure. Licensure obstacles impact the ability to recruit doctors to Alabama and limit our
ability to identify cost-effective physicians for locum tenens service. Psychiatrists are unlikely to
stay in practice if they are not able to cover their practice when they go on vacation or need
family/sick leave.

3. CALCULATING ALABAMA PSYCHIATRY DEFICIT:

Alabama has 7.1 psychiatrists per 100,000 populations while other neighboring states have 8.1
and the nation has 13.7. Alabama is below Tennessee, Georgia, and Florida with only
Mississippi below our levels (see table 1 and 2). Alabama has shortages of psychologists, social
workers, and nurses who specialize in mental health in comparison to our neighbors and the
nation (see table 3). The psychiatric workforce is rapidly aging with most over the age of 50 and
many (24%) over the age of 69(See Table 4). The national rate of growth in training of
psychiatrists is declining while the rate of growth for demand of services is rising.

Table 1. A Comparison of Clinically Trained Table 2. 2001 Estimated Numbers of Clinically

Psychiatrists in Alabama to Other Neighboring Trained Psychiatrists per 100,000 Population
States (per 100,000) in 2001
• National – 13.7
National- 13.7 • New England - 26.9
Alabama- 7.1 • Middle Atlantic - 22.1
South Carolina- 11.0 • East South Central- 8.2
Georgia- 10.1 • Alabama 7.1
Tennessee- 9.1
SAMHSA.gov 2007
Florida- 10.5
Mississippi- 6.1

SAMHSA.gov 2007

Table 3. Alabama’s Psychiatric Manpower Table 4. Age of Psychiatric

Crisis (per 100,000 citizens) in 2007 Workforce in 2002
National Regional Alabama M (71%) F (29%)
Under 50 28.7 53.1
Psychiatrists 13.7 8.2 7.1
50-60 26.9 27.9
Psychologists 31.1 15.6 13.6
60-69 20.3 9.8
Psychiatric Nursing 6.5 8.0 N/A 69+ 24.2 9.1
Social Workers 35.3 18.1 14.8
SAMHSA.gov 2007

SAMHSA.gov 2007

4. SUBSPECIALTY CARE
Specific sub-specialty services such as geriatrics and child and adolescents are in short supply in
Alabama. Published data indicates that Alabama has one of the lowest availability per capita of
child and adolescents psychiatrists in the country. Alabama had 3.9 child psychiatrists per
100,000 youths in 2001 while Mississippi had 4.0, Georgia 5.9, and South Carolina had 10.1.
Outside evaluations ranks Alabama in the bottom six states in the nation for psychiatrists and the
Alabama Department of Public Health rates most counties in Alabama as severe mental health
manpower shortage areas. Determination of numbers is difficult to accomplish because many
non-practicing physicians retain their licenses, maintain a limited practice due to age or only see

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patients on a part time basis. All available, creditable evidence points to a severe shortage of
psychiatrists with no solution in sight.

5. UNDERSTANDING THE IMPACT OF LICENSURE OBSTACLES TO PHYSICIAN

RECRUITMENT:
The present Alabama medical licensure regulations require that a person either take a state
licensing examination or a board certification examination within the last ten years of applying
for an original license. Either examination will suffice to qualify as a potential applicant for
licensure in Alabama. The national specialty board certification system is slowly moving away
from lifetime certification and towards mandatory renewable certification at a ten year intervals.
For example, a newly board certified psychiatrist who recently completed a residency must retest
in ten years while an older “grandfathered” psychiatrist has lifetime certification When older
physicians with lifetime certification are no longer within the healthcare system, the mandatory
recertification program will correct some of these problems. Many older psychiatrists hold
lifetime certificates and they will not have undergone a recertification examination or a state
medical licensure examination in the last ten years. Based on a rough estimate, Alabama has a
ten year window when many older physicians may consider relocation to this state will not meet
either requirement. Physicians rarely voluntarily retake expensive time consuming
examinations.

The Alabama Board of Medical Examiners has raised the issue of physician quality and national
standards as a justification for the present restrictive licensing system. A recent survey published
in the New England Journal fails to support the contention that the present Alabama licensure
system; i.e., using test scores and proximity in time for testing, is a safeguard against bad doctors
(See Table 5). The study actually shows that immature or erratic behavior in medical school is a
better predictor for later problems with Board. The argument that other states will eventually
adopt the “Alabama way” remains to be proven. As long as Alabama maintains itself at a
competitive disadvantage, we will continue to lose physicians as we did following the Katrina
exodus from New Orleans. Any future licensure legislation can be re-crafted to assure that future
Alabama guidance comports with new national standards; however, there is no creditable data to
indicate that 33 other state legislators are going to make licensure more difficult in states that
already experience physician shortages.

Table 5. Risk Factors for Medical

Board Disciplinary Actions
In medical school:
•  responsibility
•  self-improvement
•  initiative
•  peer relationship
•  attitude towards nurses
•  MCAT score
•  Grades yrs 1 and 2

NEJM 353:25;2673-82

The present system will create a window of vulnerability in Alabama where our restrictive
licensing procedures will limit the number of psychiatrists. The state needs a plan to manage the
shortage of psychiatrists until the vast majority of physicians recertify every ten years. Alabama
should strive to have a flexible licensing policy that mirrors the most competitive state in the
nation.
UNDERSTANDING THE SHORTAGE OF PSYCHIATRISTS IN ALABAMA
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6. UNDERSTANDING THE ECONOMIC, LEGAL, AND SOCIAL IMPACT OF THE
MENTAL HEALTH MANPOWER CRISIS IN ALABAMA
The shortage of psychiatrists impacts multiple segments of Alabama business, government, and
education. The shortage of child and adolescent psychiatry reduces the likelihood that troubled
youths can receive appropriate care and may increase the burden on the public school systems.
Many inmates within correctional facilities suffer from mental illness that complicates their
incarceration and increases the likelihood of recidivism. Substance abuse is a massive public
health, legal, and societal problem; however, Alabama has a low number of qualified
addictionologist. Alabama is becoming a retirement destination, yet the state has not produced a
geriatric psychiatrist in the last two years. Physician shortages cause public sector organizations
to hire “any available psychiatrist” in some circumstances. Economics dictate that diminished
supply increases cost and decreases availability. Persons with serious mental illness often have
multiple medical comorbidities. Alabama’s shortages of primary care doctors and nurses further
compounds problems with care. New data shows that persons with serious mental illness in the
public system have a life expectancy that is approximately one-third less than that of the general
population; i.e., twenty-five years of less survival. Nursing shortages are particularly acute as
Robert Wood Johnson Foundation identifies Alabama as having a six-percent total deficit in
nursing manpower and this number will grow to twenty-percent by the end of the next decade.
Alabama presently has no plan to correct the shortage of psychiatrists, primary care doctors, or
nurses who are the essential building blocks in any biomedical management system for person
with serious mental illness. The Deans of the Schools of Nursing for Alabama indicate that
approximately 3,000 qualified candidates for nursing schools were turned away because
Alabama lacks the capacity to train these individuals. A plan to develop a community-based
mental health services will not succeed without the presence of physicians and nurses who
require many years of training to enter the workforce.

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References:

1. Manderscheid, RW, Berry JT (Eds.), (2004), Center for Mental Health Services,
Substance Abuse and Mental Services Administration, Mental Health, United States.
www.samhsa.gov.
2. Alabama Board of Medical Examiners. Physician Licenses Application. www.albme.org.
3. World Health Organization, (2001), WHO Calls for Upgradation of Services and Trained
Manpower to Deal with Increasing Mental and Neuro Psychiatric Illness in the Countries
of WHO South-East Asia Region. www.scaro.who.int.
4. Faulkner LR, Goldman, CR. Estimating Psychiatric Manpower Requirements Based on
Patients’ Needs. Psychiatric Services 1997; 48:666-670.
5. An Action Plan for Behavioral Health Workforce Development, A Framework for
Discussion. SAMHA Publications.
6. HRSA. U.S. Department of Health and Human Services. Physician Supply and Demand:
Projections to 2020. http://bhpr.hrsa.gov.
7. HRSA. U.S. Department of Health and Human Services. Health Resources and Services
Administration. The Registered Nurse Population: Findings from the 2004 National
Sample. http://bhpr.hrsa.gov.
8. Robiner WN. The mental health professions: Workforce supply and demand, issues, and
challenges 2006; 26:600-625.
9. Faulkner LR. Implications of a needs-based approach to estimating psychiatric workforce
requirements. Academic Psychiatry 2003; 27:241-246.
10. Thomas CR, Holzer CE III. The continuing shortage of child and adolescent psychiatrists.
J. Am. Acad. Child Adolesc. Psychiatry 2006;45(9):1023-1031.
11. Nawata S, Yamauchi K, Ikegami N. Department of Health Policy and Management, School
of Medicine, and Faculty of Nursing and Medical Care. Psychiatry and Clinical
Neurosciences 2006;60:709-717.
12. Papadakis MA, Teherani A, Banach MA, et al. Disciplinary action by medical boards and
prior behavior in medical school. NEJM 2005;353:2673-2682.

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