The Growing Demand for Nurse Practitioners in Mental Health
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“The low percentage of NPs choosing mental health as their primary specialty can be attributed to various factors. One prominent reason is the persistent stigma surrounding mental health.”
Roger Rivera, PMHNP
As of 2021, more than one in five American adults have some kind of mental illness. The good news is that people are seeking help from mental health professionals in greater numbers than in years past, with more than half (56 percent) of Americans seeking or wanting to seek mental health services for themselves or a loved one.
While it’s undeniably positive that more people are interested in getting help for their mental health concerns, the behavioral health workforce isn’t large enough to accommodate the numbers of people seeking these services.
The imbalance of supply and demand makes it difficult for patients to find in-network providers and perpetuates long wait times, which is less than ideal for those in need of immediate care.
Due to the shortage of physicians and psychiatrists, the U.S. healthcare system is increasingly reliant on psychiatric-mental health nurse practitioners (PMHNPs)—mental health-focused NPs–to meet the needs of patients with psychiatric conditions, especially those who benefit from medication.
PMHNPs perform a similar role as physicians and psychiatrists; they are autonomous healthcare professionals who can diagnose mental health conditions, evaluate and monitor patients’ well-being, and generally prescribe medications when necessary (depending on their state).
Studies show that nurse practitioners (NPs) match physicians in quality of care. In fact, many patients prefer receiving care from NPs because of their strong interpersonal skills, which is essential when it comes to mental healthcare.
But PMHNPs comprise a minority of nurse practitioners (NPs) compared to other advanced practice nursing specialties, begging the question, why aren’t more burgeoning NPs choosing to major in this high-demand niche?
Meet the Experts
Roger Rivera, PMHNP, FNP
After serving in the Marine Corps for seven years, Roger Rivera earned his BSN and MSN degrees from the Inter-American University of Puerto Rico, followed by a certificate in psychiatric mental health from the University of Cincinnati. In 2017, he began moonlighting in an outpatient clinic for psychiatry in effort to become more professionally well-rounded and ended up finding his passion in mental healthcare.
As a PMHNP, he helps patients with conditions such as bipolar disorder, schizophrenia, substance use disorders, depression, PTSD, and anxiety disorders. He also holds a nurse educator certificate from the University of Florida.
Kate Hanselman, PMHNP-BC
Kate Hanselman has over a decade of experience working in mental health as a nurse, a first responder in New York, and a health professions educator. She has worked with adults and seniors who deal with family conflict, transgender issues, grief, sexual orientation issues, trauma, PTSD, anxiety, depression, anger issues, dysfunctional relationships, ADHD, behavioral issues, women’s issues, and more.
Hanselman earned an MSN from the University of Pennsylvania and a master’s in science from King’s College London.
The Important Role of NPs in Mental Health
Roger Rivera, a PMHNP who earlier worked in trauma surgery and then family care in the military, began to notice something that sparked his interest in mental health: “I observed that [primary care] providers often handled a significant portion of psychiatric work,” he says. “This further emphasized the need for specialized training in mental health and sparked my interest in delving deeper into the field.”
While primary care providers can technically diagnose mental health conditions and prescribe psychiatric medication when necessary, their role is more to serve as an entry point into the healthcare system, perform routine check-ups, and handle basic medical needs.
Because primary care providers must be educated on a wide range of health issues affecting the whole body, they don’t have the same in-depth training in mental health disorders and the delivery of psychiatric care as PMHNPs.
Experts put forth that PMHNPs’ background in nursing and their advanced education in mental health offer patients a unique person-centered experience distinct from any similar players on the healthcare team.
What Sets PMHNPs Apart
All NPs choose an area of focus in graduate school such as family primary care, adult-gerontology primary care, women’s health, pediatrics, and psychiatric/mental health. “If you’re applying for your master’s, you have to apply for a specific track to specialize,” explains Kate Hanselman, a PMHNP for the mental healthcare provider network Thriveworks.
The different NP tracks often have similar core curricula, but differ regarding advanced courses and clinical placements.
PMHNP programs revolve around diagnosing patients’ mental disorders based on the DSM5 and their clinical experiences are typically completed in mental health settings such as substance abuse treatment centers and psychiatric emergency rooms.
Most PMHNP programs also prepare students for delivering therapy and counseling: “For example, I’m fully certified in cognitive behavioral therapy because my schools gave us training on it [versus] other schools that maybe either don’t have that focus in particular or don’t train as specifically in therapy,” Hanselman adds.
While most PMHNPs focus on medication management rather than psychotherapy, the training teaches providers to take a trauma-informed approach to communicating with patients and generally improves the quality of clinical encounters.
All of this specialized education and training makes PMHNPs better suited to recognize signs of mental illness in patients and treat them more effectively—especially those who may have complex or comorbid mental health conditions.
Why Don’t More NPs Choose the Psychiatric Specialty?
The U.S. Bureau of Labor Statistics projects that nurse practitioners will be the fastest-growing occupation across industries in the U.S. within the next decade. Yet less than one in ten nurse practitioners choose to specialize in mental health.
“The low percentage of NPs choosing mental health as their primary specialty can be attributed to various factors,” Rivera says. “One prominent reason is the persistent stigma surrounding mental health.”
While many of us are aware of mental health stigma in non-healthcare environments, such as the corporate work environment and in social contexts, it can affect healthcare workers, too. In fact, stigma may deter burgeoning NPs from choosing the psychiatric specialty.
“There is stigma that still pervades—not just for people receiving care, but in the field itself,” Hanselman says. “People still think… that if you work in mental health, that [mental illness] is basically contagious.”
Over the years, various studies have shown that structural and interpersonal stigma related to mental illness in the healthcare system impacts quality of care for patients with mental illnesses and even impacts help-seeking behaviors of health providers themselves.
“Many individuals, including those in the Marine Corps, were conditioned to ignore their mental health concerns and soldier on to the next task,” Rivera says.
Like many healthcare professionals, Rivera began to realize that he was not immune to these same pressures. Data from the American Nurses Foundation found that over a third of nurses experience some sort of stigma with seeking mental health support, which is likely experienced by members of other niches within healthcare, as well.
The “hero” label that is imposed upon healthcare providers—especially those in nursing—and the expectation that they should be models of health and wellness also play into the stigma of dealing with mental health struggles as a healthcare worker.
“I came to realize that this approach [of soldiering on] takes a toll… It took years for me to integrate this understanding into my own mindset,” Rivera says.
Another factor that may be dissuading NPs from specializing in psychiatry may be coming from within academia.
Hanselman says she should have always been working in the mental health field, but wasn’t encouraged to pursue it by educators. Because she was a high achiever academically, she was steered toward work in critical levels of care, such as the ICU.
Like Rivera, she eventually realized that psychiatric care was her calling and switched gears.
Is Mental Health the Right Niche for You?
Depending on the work setting, the challenges and lifestyle of a PMHNP can vary significantly.
“Psychiatric nurse practitioners can work in all kinds of settings,” she says. “People do think of a psychiatric hospital or an inpatient facility. However, you can also work…in the outpatient setting, you can work remotely, you can work in private practice, or you can work in a clinic.”
Hanselman, who works from home, treats patients with depression, anxiety, panic, and trauma-related disorders which are safe to treat in a remote, outpatient setting.
Her days are spent meeting with patients virtually, taking notes, and documenting visits. While working from home has its appeal, the amount of documentation and screen time may be draining for healthcare workers from other backgrounds.
“Burnout also comes from the kind of work that isn’t directly clinically related and that takes away from a sense of satisfaction and purpose and mastery,” Hanselman says. “I’m not documenting for the sake of my client, necessarily. I’m documenting so that I might get paid [by insurance providers],” she explains.
Working in an inpatient setting comes with a completely different set of challenges. Patients at psychiatric hospitals are usually in crisis or severe mental distress. They may be experiencing conditions such as severe depression, suicidal ideation, schizophrenia, substance use disorder, or a combination of co-occurring disorders. Rivera, who worked in a psychiatric ward for a time, found the experience overwhelming.
“Witnessing individuals in active psychosis and mania initially made me hesitant about being part of this field. However, as I delved deeper into the neurobiology of mental health, I found it truly fascinating and felt a strong desire to learn more,” he says.
Some PMHNPs in inpatient settings report facing aggression from patients, moral distress and concerns with colleagues’ quality of practice, and low-staffing levels.
“It is crucial to recognize that providing mental health care can take a toll on one’s own well-being and long-term mental health,” Rivera adds. “Establishing personal boundaries and self-care practices is vital to prevent burnout and maintaining a genuine passion for the work being done.”
Every niche in healthcare comes with its own challenges, which is why Rivera says choosing a specialty should come from the heart.
“Guiding patients through their mental health journey is not only life-changing but also incredibly rewarding,” he says. “The feeling of being able to save lives in trauma surgery is powerful, but the impact of helping individuals with mental health struggles and guiding them toward long-term wellness is incomparable.”
Nina Chamlou is an avid writer and multimedia content creator from Portland, OR. She writes about aviation, travel, business, technology, healthcare, and education. You can find her floating around the Pacific Northwest in diners and coffee shops, studying the locale from behind her MacBook.