The psychiatric workforce shortage in the USA has been well documented. The nation is not graduating enough psychiatrists for its needs, these psychiatrists are not equitably distributed where they are needed the most, and subspecialty areas of current mental health demand (addiction, geriatrics, child psychiatry) are particularly underserved [1]. The August 2022 issue of Academic Psychiatry demonstrates that the journal’s authors are responding with evidence-based analyses of the challenges, as well as programs designed to overcome the obstacles. These papers offer insight into the problems and progress toward effective responses.

An essential aspect of addressing the shortage in the psychiatric workforce is increasing the number of psychiatry residency training slots. Critical to this increase is understanding both the potential obstacles and the opportunities. Pheister and colleagues [2] surveyed psychiatry residency and fellowship directors to find answers to these questions. They found that the primary motivation for starting new programs or expanding existing ones is the identified shortage of psychiatrists or subspecialists in the geographic areas of the respondents. The largest sources of funding for these new positions were the respondents’ own institutions followed by state and other health systems. As the lack/loss of financing was the most cited reason for the closure of the programs or the inability to expand programs, it is vital to be aware of funding resources available to programs. It is also important for psychiatric leaders to identify sources that are underutilized and to advocate effectively at the national level for more funding.

In addition to providing valuable information about what resources new training directors need, Pheister et al. [2] found that other approaches to solving the workforce crisis such as telepsychiatry, collaborative or integrative care, and training of non-psychiatrists [3] have already been adopted by many of the programs they surveyed. Another important issue highlighted by the authors is the difficulty experienced by programs in recruiting and retaining faculty. Unless psychiatry can retain a talented faculty pool for the training of its educators, it will not be effective in carrying out its mission to educate future generations.

Several papers in the August 2022 issue provide additional information about funding of the residency programs. Vincenti and colleagues [4] examine funding support provided by the Department of Veterans Affairs (VA) to deploy residents in rural areas. They provide details on the expansion of funding to psychiatry since 2014 to 2020 and compare the increases in residency positions in different geographic locations for urban and rural populations. During this period, there was an increase in residency positions at rural sites from 20 to 52 and at urban sites from 978 to 1,131. Similarly, Pheister et al. [2] found that among their respondents, funding by the VA accounted for 21% of the residency programs and 6.3% of fellowship program expansions. While the increase in VA support for psychiatry programs is encouraging, there is still plenty of room for growth. The authors report that even after many years of increasing support, in 2020 only 11 of the 25 VA hospitals in rural locations received psychiatry resident stipends. Vincenti and colleagues also found that certain urban residency programs do serve a high number of rural veterans but at the same time there remain areas with high numbers of rural patients that are still served by relatively fewer residents. They describe the challenges in addressing this maldistribution and expanding residency positions in areas where there are no established psychiatry programs for the VA to partner with.

Gates and Mohiuddin [5] discuss how the current and projected physician workforce shortage in the USA was highlighted by the COVID-19 pandemic. They examine the intersection of this deficit with the crisis in children’s mental health. There has been growing demand for child psychiatry services as anxiety and depression in youth have grown. The authors draw attention to one possible source of respite: the Resident Physician Shortage Reduction Act of 2021. This bill would add 2,000 Medicare-funded residency positions for all specialties each year for the remainder of this decade. Psychiatrists and psychiatric organizations should raise their voices in support of this bill and also emphasize the need to direct some of this proposed funding to psychiatry and psychiatry subspecialities.

International medical graduate (IMG) physicians make up an important part of the psychiatry workforce, especially in some underserved areas. Duvivier and colleagues [6] combine data from the American Medical Association and the Educational Commission for Foreign Medical Graduates to provide an updated analysis of the contribution of international graduates to the total number of active psychiatrists in the USA. They begin by reviewing some of the changes in the percentage of IMG physicians matching into psychiatry compared to the total of newly matched residents. In 2005 close to 23% of entering residents were international graduates, but in 2019 this had fallen to slightly over 16% (although given the increase in the total number of psychiatry positions, this still represented a small increase in the actual number of incoming IMG psychiatry residents).

In addition, the percentage of IMG physicians matching into psychiatry who were US citizens (mostly graduates of Caribbean medical schools) increased substantially compared with non-US citizen IMG physicians [6]. Based on their analysis, in 2020, non-US IMG physicians constituted 22% of the workforce while US IMG physicians constituted 6.5%. Although the percentage of IMG physicians as a whole went down slightly, the percentage of US IMG physicians had risen from 5% in 2010. The authors point out several aspects to these trends that are concerning. First, non-US citizen IMG physicians may increase the diversity of the psychiatry workforce and better serve immigrant and minority communities. Second, non-US citizen IMG physicians tend to take care of poorer patients in more rural areas, perhaps in part as a result of J1 Visa waiver requirements.

Several papers focus on specific subspecialty areas of workforce need. The shortage of psychiatrists in the addiction, geriatrics, and child and adolescent psychiatry subspecialties is well known [1]. Alleyne and colleagues [7] highlight the importance of retaining child and adolescent psychiatrists in the workforce. While their findings are limited by a low response rate and a much higher proportion of responses by late career psychiatrists, they do provide useful information on career satisfaction for child and adolescent psychiatrists. The authors found that high career satisfaction among the respondents of their study had positive correlations with job advancement opportunities, job enjoyment, and control. For the early career group, job enjoyment was the most significant predictor, even compared to other predictors like the number of hours worked per week. For the mid-career group, control of work assignments and duty hours were the strongest predictors of career satisfaction.

Examining the recruitment of geriatric psychiatry fellows, Agapoff et al. [8] surveyed program directors and fellows nationally. As the authors note, there has been a significant drop in geriatric fellowship applications in recent decades, simultaneous with an increased need for care of a growing elderly population. Of particular interest, the authors found that the leading reasons for choosing geriatric training were (1) appeal of the life story of the elderly patient, (2) medical aspects of geriatric psychiatry, (3) sense of societal responsibility for the aged, (4) influence of a mentor, and (5) intellectual appeal. Given the presence of narrative, medical, and societal factors in these reasons, it seems that residents may be drawn to geriatric psychiatry as a specialty that provides a truly biopsychosocial experience. Echoing Duvivier et al.’s emphasis on IMG physicians for the US workforce needs [6], the authors also report that IMG physicians made up 40% of geriatric fellows [8], and they speculate that the USA may be benefiting from the opportunity to recruit physicians from cultures with a strong tradition of respect for and obligation to the elderly.

Steiner and colleagues [9] discuss workforce development in public sector psychiatry as well as the recruitment and retention of diverse psychiatrists in the public sector. They describe the impact of a public psychiatry fellowship program in attracting psychiatry residents who are interested in developing leadership and administrative experience. The authors found that nearly all of their alumni worked in the public sector for at least some time, and a vast majority remained in this setting at the time of the study. The authors also highlight their efforts in recruiting a diverse group of candidates to the fellowship. The authors found that challenges remain in retaining the psychiatrists in the local mental health system, especially psychiatrists of color. The authors did not explore the issues that led to their alumni leaving the public sector, which is an area of focus for future research. It is vital to ensure that psychiatrists are available to patients in communities along with adequate support from other allied professionals, such as nurse practitioners, outreach workers, case managers, and physician assistants.

Killough and colleagues [10] focus on an attempt to address the particularly severe shortage of psychiatrists in rural areas. They report on the challenges and outcomes of a rural psychiatry track in the southwest. They were not able to demonstrate significant difference in the likelihood of practicing in rural/frontier/underserved areas when comparing their rural track residents with their non-rural track psychiatry residents. The authors consider whether lack of immersion in rural community and rural culture due to changes in their track over time might have diluted the impact of their program. However, they provide valuable insight into the barriers that residents perceive in this regard. Distance from family was the most commonly cited concern. Residents also raised issues of social isolation, career opportunities for partners, and quality of local schools as barriers. The authors suggest that the ability to serve rural areas through telehealth will mitigate these barriers, though it may bring the cost of further disconnection between the practicing psychiatrist and the local community/culture.

These papers in the August 2022 issue demonstrate the breadth and depth of psychiatric workforce shortages in the USA. There is no single solution to address the deficits; different aspects have to be addressed by different solutions. Psychiatrists should continue to advocate for federal and state funding for expansion of graduate medical education slots, but they also should explore every avenue of potential funding, including academic partnerships with private health care systems, resource sharing among residencies, and philanthropy. Some solutions such as telepsychiatry can help address maldistribution of psychiatrists and other mental health professionals. For telepsychiatry to be successfully implemented, progress needs to be made on the ability of psychiatrists to provide care across state lines. Advocacy and research efforts here should focus on ensuring a common licensing process across states, parity in payments, and patient outcomes.

The papers in this issue speak to work in progress by psychiatric educators and leaders. Training directors are increasing the number of training programs and positions. Researchers are studying how to increase retention and improve distribution of psychiatrists. Programs have started incorporating telepsychiatry, collaborative care, and how to work with other advance practice providers into their training curriculum. The current workforce shortage and innovations are likely to require additional curriculum and training for psychiatric residents in targeted areas: for example, increasing training in some subspecialties (geriatric psychiatry, addiction psychiatry, child and adolescent psychiatry), collaborative care, telepsychiatry, population health, and working with advanced practice providers. As educators consider what needs to be added to prepare future psychiatrists in skills they will need in their careers, they will also be forced to consider what current aspects of the curricula are no longer as relevant and might be shortened.

Addressing the unmet mental health needs in the USA will also require psychiatrists to engage colleagues from outside psychiatry. We need to advocate for and ensure that the residents from primary care specialties like medicine, emergency medicine, and obstetrics and gynecology are taught about psychiatric topics and their preparedness to meet mental health needs in their practices [11]. In addition, we need to continue to increase public awareness of the psychiatric workforce deficits and its impact on the people of the USA and to harness this awareness for more effective advocacy efforts at the state and national levels.