It is an irony that troubles health-care providers and policymakers nationwide and in Ohio: Even as public awareness of mental illness increases, a shortage of psychiatrists worsens.

In vast swaths of America, patients face lengthy drives to reach the nearest psychiatrist, if they can even find one willing to see them.

Ohio is no exception, said Dr. Mark Hurst, medical director for the Ohio Department of Mental Health and Addiction Services. There are more Ohio psychiatrists practicing in urban areas so there are some shortages in rural communities, Dr. Hurst said.

Some states are promoting wider use of long-distance telepsychiatry to fill the gaps in care. In Ohio, Columbus-based Nationwide Children’s Hospital is using a pilot telemedicine program to reach children and adolescents in the rural areas of Southeast Ohio. And Coleman Professional Services that is based in the Akron area provides psychiatric services to people in Lima using telemedicine devices, he said.

In Texas, which faces a severe shortage, lawmakers recently voted to pay the student loans of psychiatrists willing to work in underserved areas. A bill in Congress would forgive student loans for child psychiatrists.

Even with such efforts, problems are likely to persist. A recent survey by the Association of American Medical Colleges found that 59 percent of psychiatrists are 55 or older, the fourth oldest of 41 medical specialties, signaling that many may soon be retiring or reducing their workload.

Charles Ingoglia, a vice president of the National Council for Behavioral Health, helps coordinate a network of 2,300 nonprofit clinics nationwide that provide mental health services.

“I’m not aware of any part of the country where it is easy for our members to find psychiatrists,” he said.

Statistics help tell the story. According to the American Medical Association, the total number of physicians in the United States increased by 45 percent from 1995 to 2013, while the number of adult and child psychiatrists rose by only 12 percent, from 43,640 to 49,079. During that span, the U.S. population increased by about 37 percent; meanwhile, millions more Americans have become eligible for mental health coverage under the Affordable Care Act.

Federal health authorities have designated about 4,000 areas in the U.S. as having a shortage of mental health professionals — areas with more than 30,000 people per psychiatrist.

What’s behind the shortage of psychiatrists?

New graduates are not replacing those in the the field that are planning to retire. “It’s just a sheer numbers issue,” Dr. Hurst said.

Dr. Renee Binder, president of the American Psychiatric Association, says the perception of inadequate pay is a factor in discouraging some medical students from choosing psychiatry as a specialty. The latest federal data shows a mean annual wage of $182,700 for psychiatrists, slightly below the mean for general practitioners and 28 percent below that for surgeons.

According to the U.S. Bureau of Labor Statistics there are about 1,060 practicing psychiatrists in Ohio with an average annual salary of $185,110.

Some psychiatrists are switching to a cash-only practice out of frustration with what they view as inadequate reimbursement from government and private insurance plans.

Another problem, Dr. Binder said, are the paperwork requirements imposed by Medicare and private insurance companies. “That interferes with our ability to have the time to sit with our patients,” she said. “We need to decrease the administrative burden and increase the compensation.”

Among today’s medical students, there’s excitement about scientific developments in psychiatry but also concern about the profession’s stature and pay levels, according to Dr. Darrell Kirch, president of the medical colleges association.

“There remain issues of stigma around mental disorders,” said Dr. Kirch, a psychiatrist by training. “The people who suffer most from that are the patients, but we still see cases where psychiatry is devalued by some in the medical profession.”

Looking forward, mental health experts identify two primary avenues for addressing the shortage.

Telemedicine

One is to expand the use of psychiatric telemedicine, enabling psychiatrists to serve more patients in expanded regions, including individuals with limited mobility such as elderly people and prison inmates. Several states, including South Carolina, North Carolina, and Michigan, have implemented extensive telepsychiatry programs.

There’s some wariness about forgoing face-to-face interaction with patients, but the leading psychiatric organizations believe the benefits of expanding telepsychiatry far outweigh any negatives. Dr. Sy Saeed, a leader of North Carolina’s program from his base at East Carolina University, says it usually takes only a few moments for a new patient to feel at ease with the two-way video technology.

“It’s the same for psychiatrists,” he said. “Once I’ve engaged in the visit for a few seconds, I also forget that it’s occurring via telepsychiatry.”

The other strategy is known as collaborative care, in which mental health specialists provide consultation to other health care providers. Related to this are ongoing efforts to ensure that primary-care physicians have solid training in mental health, so they can handle some straightforward cases themselves and make proper referrals for more complex cases.

In Ohio, primary care physicians are playing a bigger role and they do an excellent job of treating people with psychotic problems, Dr. Hurst said. “More than half of folks are with psychiatric disorders are receiving care from their primary care physician,” he said.

Sita Diehl, director of state policy and advocacy for the National Alliance on Mental Illness, believes collaborative care has enormous promise, provided that the non psychiatrists — whether doctors, nurse practitioners, counselors, or social workers — receive specialized training.

“They are the boots on the ground,” she said. “The general principle is to enable them to practice to the ceiling of their expertise.”

In contrast to the calls for collaboration, there is continuing friction over whether America’s psychologists, if properly trained, should have the same authority as psychiatrists to prescribe psychiatric medication. Three states — New Mexico, Louisiana, and Illinois — have granted this authority to qualified psychologists, but fierce opposition from psychiatric groups has blocked such moves in other states.

“Medications for psychiatric illness are really powerful ... people can die from these,” Dr. Binder said. “You need a medical background to prescribe them effectively.”

Psychologist Daniel Abrahamson, who heads the American Psychological Association’s state advocacy office, says such fears “are not based on the facts” and cites the lack of problems in the three states that eased restrictions.

He said the psychologists who would obtain prescription authority have extensive training in assessing and treating mental illness and would help address the unmet needs for psychiatric medication.

“It would behoove everybody to work together,” he said. “Unfortunately, the old issues keep getting in the way and people try to protect their turf.”

Geographically, the distribution of psychiatrists across the United States is uneven. According to AMN Healthcare, a health-care staffing company, Massachusetts, Rhode Island, Vermont, Connecticut, and New York have more than 15 psychiatrists per 100,000 people, while Wyoming, Texas, Iowa, Mississippi, Indiana, Nevada, and Idaho have fewer than six. In Texas, about 200 of the 254 countries are designated as lacking enough psychiatrists.

First Published October 12, 2015, 4:00 a.m.