Doctors in Dialogue
The Ongoing Crisis in Psychiatry: How to Address Staffing Shortages in Behavioral Healthcare
An interview with Jacob Appel, MD, and Matthew Erlich, MD
The United States is facing a crisis in psychiatric care. And while some blame the COVID pandemic for accelerating current issues, the deeper truth is that many of the cracks we’re seeing today were visible years ago—they've just widened under pressure.
As psychiatrists deeply engaged in both frontline care and health policy, we’ve watched this crisis unfold from different angles. What we’ve seen is alarming, frustrating, and, unfortunately, deeply familiar. We're facing a crisis among our workforce, and hence, care delivery.
Below is our extended conversation on where the crisis began, how it’s evolving, and where we go from here.
A Slow Burn, Then a Blaze
Dr. Matthew Erlich: Let’s be clear—this didn’t start with COVID. We’ve known for a long time that psychiatry’s workforce is aging. Even before the pandemic, we were on a trajectory where retirements were poised to outpace new practitioners joining the field.
The plan, such as it was, was to manage that carefully. But COVID changed everything. It didn’t just increase demand; it reset clinicians' appraisal of the field and how long they sought to practice. Whether due to burnout, stress, safety concerns, or a reevaluation of work-life balance, the workforce shrank. At the same time, the pandemic triggered or exacerbated mental health conditions across the population. We don’t have the full epidemiological picture yet, but we know this much: more people need care, and fewer are available to provide it.
Dr. Jacob Appel: And for those still practicing, many are shifting how they work. Psychiatry is still popular among medical residents, but the nature of practice is changing. Fewer young psychiatrists are going into inpatient care or public sector work. Instead, they’re choosing outpatient settings, short-term medication management, or telepsychiatry. That shift has long-term implications, particularly for underserved and seriously ill populations.
The Telepsychiatry Trade-Off
Erlich: Telepsychiatry was a lifeline during the early pandemic. It kept people connected to care and provided flexibility for clinicians. In many ways, it still does.
But it’s a double-edged sword.
While telehealth improves access and convenience, it also makes it easier for clinicians to not be involved in ‘boots on the ground’ team-based, community-rooted care. The temporary suspension of policies like the Ryan Haight Act, which previously required in-person visits to prescribe controlled substances, made it even more attractive. Suddenly, psychiatrists could work from home—or from across the country.
This trend threatens inpatient psychiatry. It weakens the fabric of local, public systems, and ultimately, it could negatively impact patients who need the most support.
The Great Divide in Access
Appel: Here’s what it looks like for the average person. Say you’re middle class. You have a family member in a mental health crisis—not severe enough for the ER, but serious enough that they need a psychiatrist.
Good luck.
If you’re wealthy, you can pay out of pocket. If you’re on Medicaid, maybe you’ll find someone eventually. But if you have private insurance—Cigna, United, Oxford—it’s nearly impossible to find a psychiatrist who takes it. Waitlists are months long. And if your family member has a history of suicidality or substance use? The odds get worse.
We’re seeing a system where the “worried well” can get care, and the most vulnerable—those who truly need it—get boxed out. That's not just unethical. It's unsustainable.
Erlich: This same gap plays out in hospitals. Patients with serious mental illness—especially those with forensic histories, substance use disorders, or homelessness—are often dismissed before they even speak. Labeled “treatment-resistant” or “frequent flyers,” they may move from one facility to another, never receiving sustained, effective care. And, thus, impeding community engagement, community tenure, and real recovery.
Systems Under Siege
Appel: Let’s talk about the guild model. Psychiatry—and medicine as a whole—functions like a closed loop. We control the number of residency slots. We control the flow of new providers. You can’t just open a residency program. It takes funding, institutional buy-in, and federal approval. And historically, we’ve kept numbers low to maintain reimbursement rates.
That system might have worked in the past. But it’s not sufficient now. We can't scale fast enough to meet today’s needs.
Erlich: And it’s not just psychiatrists. Nurse practitioners, physician assistants, and licensed mental health counselors are filling the gaps. I work with many talented NPs, counselors, and peers. They’re essential to a multidisciplinary model.
But there’s a line between collaborating and replacing. If the goal is simply to cut costs by substituting less expensive providers, then quality of care suffers. We can’t build our future around that.
There’s similar pressure between psychologists and social workers. Social workers are increasingly taking on responsibilities once held by psychologists. AI is beginning to handle assessments. The field is shifting rapidly, but not always thoughtfully.
Burnout, Bureaucracy, and the Business of Care
Erlich: We’re also seeing a dramatic shift in employment models. More and more psychiatrists are employed by large health systems. That changes how care is delivered—and how priorities are set.
Appel: We’ve essentially turned community care into a luxury. And the public systems—the safety nets—are taking on the most complex, least profitable patients. They get the least reimbursement but carry the greatest burden.
That’s not a viable business model. And it’s certainly not a compassionate one.
The People Left Behind
Erlich: This all lands hardest on those with serious mental illness. People who are the most vulnerable with deep trauma histories, poor social supports, and multiple comorbidities.
These are not “treatment-resistant” patients. They’re patients resistant to fragmented, underfunded systems.
Recovery is possible—but only with coordinated, community-based care. That means investing in Assertive Community Treatment (ACT) teams, peer support, housing programs, and integrated medical care. It means expanding access without diluting quality.
Right now, those supports are vanishing. Many community providers lost funding during COVID and haven’t recovered. The result is a dangerous gap between hospital discharge and community reentry.
Appel: And the tragedy is that we know how to help these individuals. We have the models. We have the workforce. What we don’t have is enough training slots. Enough funding. Enough collective will.
Twenty years ago, psychiatry didn’t even fill the match. Today, there are only six unfilled spots across the entire country. That’s not a recruitment issue. That’s a bottleneck of our own making.
What Needs to Change
Appel: Psychiatry needs to take ownership of this problem. The people most affected by this shortage—patients with severe mental illness—don’t have the social or political power to demand reform. But we do.
We need to be more proactive. We need to lobby for expanded training, better reimbursement for public sector work, and policy changes that support long-term recovery—not just short-term stability.
Erlich: We also need to embrace a team-based model. I support bringing in more NPs, PAs, and counselors—so long as we do it thoughtfully. We can’t just bring more folks into the system. That will help. We also need to ensure high standards, solid training, and shared accountability.
Ultimately, it’s about recovery. The goal is not just to discharge from the hospital. The goal is reintegration into the community, long-term stability, and restoring dignity.
We can’t achieve that without people—and systems—dedicated to making it possible.
Final Thoughts
This isn’t a problem we can ignore.
The crisis in psychiatry impacts other services —health care as a whole, homelessness, incarceration, and education. It affects families, communities, and the very fabric of society.
We need action. We need investment. And we need to recognize that the solutions won’t come from outside. These resources have to come from within—from those of us in the field, who see the impacts firsthand and believe we can do better.
Because we must.