South Carolina and the rest of the country are facing a terrible math problem when it comes to mental health: There are not enough doctors to meet a growing number of patients. While the Palmetto State looks to expand access, other providers may be needed to fill in the gaps.

In a ranking of states by the number of psychiatrists and psychologists available per person, South Carolina is near the bottom, according to a new report from the Association of American Medical Colleges. The state has one psychiatrist for every 20,000 people and 13 psychologists for every 100,000 people. Among its 46 counties, 18 have no psychiatrist at all. It is a pattern seen across the country, particularly in the South and Midwest.

“The demand is increasing and the resources are decreasing,” said Dr. LalithKumar Solai , vice chair for clinical services in the Department of Psychiatry at Medical University of South Carolina. “That makes it particularly challenging in meeting the needs of patients, most importantly in a timely fashion.”

Wait times for psychiatric patients have gone up 40 percent nationally and are even longer for more specialized care, he said. One in five adults had a mental illness in the U.S. in 2020, but more than 50 percent did not get treatment, with one of the significant barriers a lack of psychiatrists and psychologists, the new report found.

That lack of access to mental health services has been a concern for Gov. Henry McMaster and state officials, and it has been a focus of special funding from the General Assembly. It resulted in a few notable projects through the S.C. Department of Health and Human Services:

• Increasing the number of counselors in schools by 66 percent to nearly 1,000 across the state
• Starting a new psychiatric health system in Florence in partnership with the city, MUSC and McLeod Health
• $45.5 million in grants to 13 hospitals to build Emergency Departments dedicated to behavioral health and crisis care

California took a similar approach about 12 years ago, which appears to be working well, said Dr. Frank Drummond, medical director for Live Oak Mental Health and Wellness, part of Trident Health System. Trident is one of the health systems that got the new grants. 

About 10 to 30 percent of patients who show up at the ER are there for behavioral health issues, and a dedicated behavioral health unit can have specially trained staff who know specifically what level of care they need, he said. The units, which can treat patients from 23 to 72 hours, can do a lot of stabilization in that short period of time or refer patients to a higher level of care, which many may not need.

“I really applaud the state of South Carolina for adopting this,” Drummond said. “It’s a big step. And it’s not a stopgap. It’s a permanent need, in my opinion.”

There are a number of reasons why a regular ER is unsuitable for behavioral health patients, said Kristina Sedra, assistant chief nursing officer at Live Oak whose background is in emergency nursing.

“It’s very busy, there’s a lot of noise,” she said. “Some of the things they are seeing and hearing, they are not conducive to keeping a mental health patient safe and not exacerbating their symptoms.”

After rolling out the programs for schools and new psychiatric ERs, S.C. Health and Human Services plans to ask for more funding next year for those programs, as well as to enhance middle-intensity community-based services, said spokesman Jeff Leieritz. That is in line with what the medical college group is asking for, and with South Carolina doctors, as well.

Growing the pool

Overall, residency slots to train new doctors in any specialty have been largely unchanged for years, but there are efforts to specifically increase programs for psychiatrists nationally and in South Carolina.

Part of MUSC’s effort in the Florence area, for instance, includes starting new residencies that would include psychiatry, Solai said. That would mean eight new positions each year for the four-year psychiatry program.

A new one is underway in Orangeburg, as well.

Nationally, HCA Healthcare, which owns Trident in the Lowcountry and Grand Strand Medical Center in Myrtle Beach, has increased from eight to 17 psychiatry residency programs over the last eight years, Drummond said. There has also been discussion about starting a program in Charleston in association with Live Oak, he said.

“There is an investment in the HCA company to really double down on education,” he said.

But a doctor-based system may be part of the access problem, as well, Solai said.

“Everything is set up around services being provided by a psychiatrist, and that’s where the gridlock is,” he said.

Instead, a multitiered approach with other providers might be better. Patients might start out at a primary care level, where their family doctor might refer them to a licensed counselor or advanced nurse practitioner, perhaps even in the same practice, who could begin to meet their needs, Solai said.

“I see this as seeing the patients where they are, in the community,” he said.

Psychiatrists could then be freed to see the more acute cases, such as patients in psychotic or manic episodes.

HCA has also embraced this approach, said Rick Paczkowski, regional vice president for the Behavioral Health Service Line in the South Atlantic and MidAmerica Divisions.

“As the need for psychiatry continues to increase, there has been a need for other licensed clinical professionals, as well,” he said. This includes advanced practice nurse practitioners and licensed professional counselors, both inside the hospital and in outpatient services.

South Carolina and many other states have recognized the need for greater access, but what can also be a problem is where patients end up within the system, Paczkowski said. The other professionals can be the ones guiding a “smooth transition between available services” that ensures patients don’t end up in the ER because they don’t know where else to turn, he said.

“They are the ones who really help drive and help direct” patients, Paczkowski said.

It’s also one of the reasons outpatient services have become such an important part of the services at Live Oak since it opened in June, particularly for adolescents, where there is a dearth of services in South Carolina.

Live Oak has already gotten referrals from across the state for those patients and had to ramp up its outpatient program for them quicker than expected, Paczkowski said. It’s also led the center, which is licensed for 60 beds, to consider moving more quickly to 84 beds, which it can do without new construction by adding beds to some current rooms.

“As we continue to assess the population, as we continue to assess the demand for the services, I could see that evolving very quickly,” Paczkowski said.

The future of mental health service in South Carolina should be this different model, said Solai of MUSC. His own estimate, using data from the federal Health Resources and Services Administration, shows a deficit of 350 psychiatrists by 2030 but a surplus in other providers, such as school counselors and social workers. Solai is grateful that the state is already investing in rural areas and those in greatest need, and believes South Carolina is on the right track. But it is a long road.

“I think we could probably be in a better place by 10 years from now,” he said.