Filling the Gaps in the Behavioral Health Workforce

The United States faces a growing shortage of licensed behavioral health care specialists—psychiatrists, psychologists, and clinical social workers—and that shortage comes at a time when rates of mental illness and substance use disorder (SUD) are high and rising. The shortage has severely limited access to treatment, particularly among underserved communities. To help address the access gap, federal policymakers should take steps to foster a behavioral health workforce that extends beyond licensed professionals.

Through regulation and legislation, policymakers and lawmakers should build on previous modest steps in two areas. First, they should nurture a greater role for behavioral health support specialists (BHSSs)—peer specialists, community health workers, and paraprofessionals—in delivering critical nonclinical behavioral health services and freeing up the licensed behavioral health workforce for more important tasks. Many states, communities, and insurers have begun to recognize the vital role of BHSSs in delivering such services and to rely on them more fully as part of teams that administer comprehensive care.

Second, policymakers and lawmakers should augment the behavioral health care that patients receive by leveraging support networks that exist within communities but that often go unused for this purpose. In particular, they should encourage greater use of community-initiated care (CIC), which empowers community members to assume some behavioral health responsibilities when appropriate and trains those in other fields (e.g., educators, faith-based leaders) to respond to individuals’ mental health needs.

Behavioral health services in the U.S. are in alarmingly short supply, due in large part to a shortage of providers and the decision by many providers not to participate in insurance networks. As of March 2021, approximately 37% of Americans (122 million people) lived in what the Health Resources and Services Administration (HRSA) calls “mental health shortage areasa.” In fact, the U.S. has noticeably fewer behavioral health providers than Canada, Switzerland, and Norway.

HRSA projected that for certain specialties the shortage could reach as many as 35,000 full-time employees by 2030, with most states facing shortages within their borders. The dearth of trained workers is so severe and so strained by the growing demand for services that the deficit cannot be adequately addressed through a redistribution of resources.

Even before COVID-19, the need for a strong behavioral health workforce was great. In 2019, just more than 1 in 5 adults in the U.S. (51.5 million) had a mental health condition. That year, 19.3 million adults experienced a SUD, and 9.5 million faced both SUD and mental health conditions.

By 2019, workforce shortages were a persistent challenge for a myriad of health care professions, especially in rural and underserved communities. For behavioral health in particular, fewer than half of adults with mental health conditions (nearly 26 million) received services in 2019, and the percentage was lower in Black and Latino communities. More than 85% of people with a SUD did not receive treatment that year. The scale of unmet behavioral health needs will likely have profound implications on other areas of society, including work productivity of those individuals who did not receive the services they needed.

The shortage of behavioral health care workers has caused other problems as well. Mental health disorders are a leading cause of hospitalization: From 2017 to 2019, the percentage of emergency department (ED) visits that led to hospital admissions was 52% higher for adults with mental health disorders than for those without them. Mental health-related ED visits strain hospital schedules as well: On average, these visits take roughly 42% longer than nonpsychiatric visits.

In addition, behavioral and physical health conditions are commonly diagnosed in a patient at the same time, putting still greater strain on behavioral health care providers. To be sure, the integration of behavioral and primary health care has emerged as a cost-effective way to improve the quality of care for individuals with such comorbidities. However, without a robust health care workforce that can address a wide range of behavioral and physical issues, the ability to integrate care is limited.

The pandemic only worsened the rising rates of behavioral health problems and the workforce shortage. For starters, the number of individuals with mental health issues rose. A May 2020 survey found that mental health conditions tripled during the peak of stay-at-home orders in April 2020, compared with two years earlier. That percentage spiked to more than 41% in 2021.

Meanwhile, after decades of rising overdose deaths from prescription opioids, heroin, and synthetic opioids, overdose deaths reached a record. In 2021, according to the Centers for Disease Control and Prevention (CDC), 107,622 died of overdoses—a 15% increase over the 93,145 in 2020—and there are still over 102,000 deaths in the 12-month period ending in June 2022. COVID-19 also exacerbated the opioid crisis, with overdose deaths rising 30% from 2019 to 2020.

At the same time, COVID-19 intensified the health care worker shortage, with staff burnout accelerating the already high rates of worker attrition. The pandemic put unprecedented stress on health care professionals (nurses, doctors, physician assistants, nursing home workers, and other support staff), including those who work in behavioral health. The effects were particularly traumatic for frontline staff, who faced co-worker deaths, isolation from their families, and an overwhelming loss of patient life. Because strict hospital protocols kept families away from patients, nurses were often the last people to comfort the dying. These restrictions likely had profound implications for families and individuals’ mental health.

To help address the growing shortage of licensed behavioral health care specialists during this critical time, BPC researched BHSSs and CIC and interviewed experts and stakeholders. Building on our previous work, BPC undertook this project to develop policy recommendations for the executive branch and Congress that would strengthen the role of the nonclinical workforce in support of licensed behavioral health professionals. If implemented, our recommendations would quickly improve access to behavioral health care.