A constant lack of services and burdensome workloads plague the mental health landscape in Iowa.

In 2012, Iowa had 236 professional psychiatrists. In 2021, the state was down to 212, in contrast to the growing population.

According to the Treatment Advocacy Center, Iowa ranks last in the nation with their 64 state psychiatric hospital beds. According to the site, a minimum of 50 beds per 100,000 people is considered necessary to treat a populace including those with severe mental illnesses – SMI.

Iowa has just two beds per 100,000, not including private beds within the state.

SMI is a subset of AMI – any mental illness.  Mental illness is common, affecting more than one in five American adults; serious mental illnesses are those that substantially interfere with or limit one’s life. Bipolar disorder, major depressive disorder, and schizophrenia are examples of SMI.

The Treatment Advocacy Center estimates that just over 84,000 people in Iowa suffer from varying forms of SMI with over 34,000 receiving help each year. This leaves roughly 50,000 people without treatment.

Time runs short to provide a solution.

State officials have tried to alleviate the mental healthcare shortage, including a pitch from Gov. Kim Reynolds on Jan. 23, 2024. Reynolds proposed to consolidate the 13 mental health and 19 substance use regions into seven “unified behavioral health districts” that would hopefully result in a “greater investment on the ground; improved connectivity between providers, districts and the state; and most importantly, treatment delivered to Iowans when and where they need it.”

This comes at a time when the University of Iowa is working to provide outpatient care in Washington and Van Buren counties. This helps increase the university’s psychiatry reach for areas with minimal coverage.

Reynolds also signed a bill in 2022 that included funding for 12 added positions for each residency class at UI – amended in 2023 to add nine psychiatry residencies and two psychiatric fellowships. This bill would allow students to work at five designated state facilities if approved by the Accreditation Council for Graduate Medical Education.

However, accreditation halted. Three of five potential sites do not have a board-certified psychiatrist to perform the duties required. The current psychiatrists in the program experience heavy workloads, according to Jodi Tate, UI’s Clinical Professor of Psychiatry and Vice Chair of Education, in a recent discussion with lawmakers.

The causes of a psychiatry shortage

It is easy to confuse the roles of the various mental healthcare providers. Put simply, psychiatrists are medical doctors who diagnose mental disorders and focus on chemical imbalances in the brain; they can prescribe medication. They differ from clinical therapists who are not able to diagnose or prescribe medications.

Psychiatric Nurse Practitioners – NPs – also play an important role.

Green Counseling Services’ Clinical and Medial Director and Psychiatric Nurse Practitioner – NP – Jennifer Meether believes schooling, location and insurance are prime causes of an Iowa psychiatry shortage.

“Mental health is not a specialty that everybody enjoys. I think that you have to have a certain personality, and view of the world and people in general, to enjoy psychiatry,” Meether said. “You have to be pretty empathetic; you have to understand that you’re going to see people from all walks of life. That’s not everybody’s jam.”

Schooling is an extensive and expensive trip for trained psychiatric physicians. First, they need to obtain a bachelor’s degree in a related field of study. Then, they must complete a Doctor of Medicine or Doctor of Osteopathic Medicine through medical school.

Different scholarships exist to help students get through school. Some, like the Iowa PRIMECARRE Community Scholarship Program, have conditions stating the student must return to the community after they finish the program. Although a smart way to help psychiatry students and the community, some students might avoid these types of scholarships.

“The job market looks a little bit different here as opposed to places like California or Texas where they have lots of options [or] may pay more,” Meether said. “A lot of providers here that I have met grew up here. I think that if you were born and raised here, [you’re more likely] to stay here because you know what it’s like to live in a small town… Maybe that wouldn’t be as appealing for somebody that grew up in a larger area.”

“[Additionally], we all have bills to pay and an education to pay off,” she continued. “If you know you’re going to school for psychiatry, that’s a lot of time in school. I think it’s all kind of folded in on itself as reasons why people maybe don’t stay here.”

The reach of this epidemic is felt at every corner of the state, from small-town farmland to the scattered big cities, because of outside factors which further hamper coverage.

“In the West Des Moines market, I would say there are fewer options, especially for clients that have Medicaid or State insurances,” Meether said. “There are not as many providers here that will take those insurances, [which] can be really limiting and change the mental health landscape for patients seeking care.

“There’s lots of insurance caveats that can make getting mental healthcare difficult. I always encourage patients to call the number on the back of their insurance card to see what their mental health coverage is.  Just because they have insurance, and their insurance is accepted, doesn’t mean that they have mental health coverage. There’s a lot of aspects like that impacting [the mental health landscape].”

Meether also worked in Waterloo and noticed a shortage there as well. Waterloo shares a Northern Iowa University campus with neighboring Cedar Falls, something that potentially relates to their mental health coverage.

“I would say that colleges in general tend to impact the level of services because they know that there are going to be a lot of students that come from all over the place to go to school, and then they’re going to need care,” Meether said. “[In Waterloo], there were lots of positions, lots of opportunity. I would say it was still apparent that there was a mental health shortage. We had tons and tons of patients that couldn’t get services and I feel like there were lots of options there.”

When people can’t get the mental health services they need, whether because they are not available or because they hesitate to seek them out, they sometimes turn to self-medication. This includes alcohol and other recreational drugs. 

According to the Iowa Office of Drug Control, 429 people lost their lives due to synthetic opioids in 2021. Most were cases of common street drugs like cocaine and heroin laced with fentanyl. Fentanyl is becoming an ever-increasing issue that puts a public deprived of mental health services in an even worse position.

While lawmakers decide how to deal with the problem, more people suffer.

One step of the larger solution: NPs

Expanding the role of nurse practitioners in the mental health landscape could help Iowa recover from this shortage of psychiatry services.

As previously stated, Meether is a psychiatric nurse practitioner, or an NP. NPs are not psychiatrists but their roles are largely the same.

“[NPs] have a very similar scope to a regular psychiatrist in Iowa, we’re allowed to practice independently,” Meether said. “I diagnose, evaluate, treat, just the way that a psychiatrist would.”

The differences between psychiatrists and NPs are miniscule but involve schooling and governmental restrictions. Psychiatrists must attend medical school and can specialize in various fields of mental health, solely practicing in that field if they so choose.

An NP has options. In some areas, their minimal requirement is a Master of Science degree in nursing. In other areas, their minimal requirement is a graduate nursing degree, specialized in a population focus. NPs can specialize in all fields that a psychiatrist can but tend to work in clinical/private settings. This means they’ll see more people with a diverse set of symptoms rather than sticking to one field.

Meether specializes in attention-deficit hyperactivity disorder – ADHD. She described a normal session with a patient who will be prescribed medications.

“I definitely think [mental healthcare] has to be tailored to each individual client. I try to make it a really warm and open experience so that we can talk about whatever is most important to them [to] create a plan together,” Meether said. 

“Each type of medication has its place. I try to be really open when clients come in and say, ‘Hey, I’d really like to avoid this type of medication’ or ‘I’ve had bad experiences with this type of medication.’ I try to take all of that into account when we’re prescribing medications because I feel like if you have to put something inside of your body to alter your brain chemistry, you should feel comfortable doing that every day, or you’re not going to be compliant, and then it’s not going to be helpful.”

As for governmental restrictions, psychiatrists are allowed to practice everywhere in the United States of America while NPs are not. Iowa is one of 30 states and U.S. territories that give NPs full practice rights.

Fifteen states and U.S territories have reduced NP policies; the closest to Iowa is Illinois. Eleven states highly restrict NPs, most notably California, Florida and Texas. NPs in these environments face restrictions in one or more aspects of their job, sometimes work under a psychiatrist and are open to career-long scrutiny.

Allowing NPs full practice rights gives hope that Iowa can fulfill the demand created by psychiatry shortages. It does not fully relieve the broader mental healthcare shortage or the immediate Iowa shortage, however.

More about Meether and Green Counseling Services: Meether works in Green Counseling Services’ West Des Moines location and is one of two NPs at the private practice. The company also has an Iowa City, Coralville, Waterloo and Davenport location. Meether has worked for the practice since June of 2022.