The federal government is involved in mental health care in various ways, including direct provision of services, payment for services, and indirect support for services (e.g., grant funding, dissemination of best practices, and technical assistance). Policymakers have demonstrated interest in the federal government's broad role in mental health care. They have done so primarily by holding hearings and introducing legislation addressing the interrelated topics of quality of mental health care, access to mental health care, and the cost of mental health care. The mental health workforce is a key component of mental health care quality, access, and cost. The quality of mental health care, for example, is influenced by the skills of the people providing the care. Access to mental health care depends on the number of appropriately skilled providers available to provide care, among other things. The cost of mental health care is affected in part by the wages of the people providing care. Thus, an understanding of the mental health workforce may be helpful in crafting legislation and conducting oversight for overall mental health care policy. It is important to note that, while the federal government has an interest in the mental health workforce, and federal initiatives may affect the training of mental health care providers, for instance, most of the regulation of the mental health workforce occurs at the state level. State boards determine licensing requirements for mental health professionals, and state laws establish their scopes of practice. This report begins with a working definition of the mental health workforce and a brief discussion of alternative definitions. It then describes three dimensions of the mental health workforce that may influence quality of care, access to care, and costs of care: (1) licensure requirements and scope of practice for each provider type in the mental health workforce, (2) estimated numbers of each provider type in the mental health workforce, and (3) average annual wages for each provider type in the mental health workforce. The report then briefly discusses how these dimensions of the mental health workforce might inform certain policy discussions. No consensus exists on which provider types make up the mental health workforce. While some define the workforce as a broad range of provider types, others take a more narrow approach. For example, the National Academy of Medicine (NAM)--a private, nonprofit organization that aims to provide evidence-based health policy advice to decisionmakers, often through congressionally mandated studies--has conceptualized the mental health workforce broadly, including primary care physicians, psychologists, nurses, mental health and substance abuse counselors, care managers and coordinators, and social workers. The Substance Abuse and Mental Health Services Administration (SAMHSA)--the public health agency within the Department of Health and Human Services (HHS) that leads efforts to improve the nation's mental health--has defined the mental health workforce to include psychiatry, clinical psychology, clinical social work, advanced practice psychiatric nursing, marriage and family therapy, substance abuse counseling, and counseling. Previously, SAMSHA's definition also included psychosocial rehabilitation, school psychology, and pastoral counseling and excluded substance abuse counseling. The Health Resources and Services Administration (HRSA)--the public health agency within HHS with primary responsibility for increasing access to health care (including mental health care) for vulnerable populations --provides a more narrow definition of the mental health workforce that is tied to existing federal programs aimed at alleviating provider shortages (e.g., Medicare bonus payments and health workforce recruitment programs). Eligibility for such programs is determined in part by the designation of a Mental Health Professional Shortage Area (MHPSA). The MHPSA designation is based on a limited number of core provider types because it is intended to identify the most extreme workforce shortages in order to target federal investments. For purposes of designating MHPSAs, HRSA has identified mental health providers as licensed psychiatrists, psychiatric nurses, psychiatric social workers, clinical psychologists, clinical social workers, and family therapists, who meet specified training and licensing criteria. Notably, this definition is limited to highly trained mental health professionals. In conceptualizing and outlining the mental health workforce, this report relies on the HRSA definition of mental health providers, including clinical social workers, clinical psychologists, marriage and family therapists, psychiatrists, and advanced practice psychiatric nurses. For each of the five mental health professions, Table 1 summarizes licensure requirements (including degree, supervised practice, and exam) and Table 2 summarizes scope of practice; each of these terms is explained briefly below. Although the licensure requirements vary widely across provider types, the scopes of practice converge into provider types that generally can prescribe medication (psychiatrists and advanced practice psychiatric nurses) and provider types that generally cannot prescribe medication (clinical psychologists, clinical social workers, and marriage and family therapists). All provider types in this report can provide psychosocial interventions (e.g., talk therapy). Administration and interpretation of psychological tests is generally the province of clinical psychologists. Licensure requirements are the minimum qualifications needed to obtain and maintain a license in a specific health profession. These requirements are generally defined by state licensing boards--independent entities to which state governments have delegated the authority to set licensure requirements for specified professions. State licensing boards generally have responsibility for verifying that requirements to obtain (and maintain) a license have been met, issuing initial and renewed licenses, and tracking licensure violations, among other activities. Table 1 focuses on licensure requirements that are common across many states; it generally does not address state variation. Across all provider types, the table addresses licensure for independent clinical practice, although some disciplines offer licensing at lower practice levels or provisional licensing. The table describes requirements to obtain a license and does not include requirements to maintain a license (e.g., continuing education). The degree noted in Table 1 indicates the minimum level of education generally required to be licensed for independent practice. For the mental health professionals outlined in this report, licensure for independent practice requires the completion of graduate education. Table 1 generally does not include degrees that are prerequisites for graduate education (e.g., a bachelor's degree) or degrees beyond those required for licensure (e.g., a doctoral degree available in a discipline where a master's degree is qualifying for licensure for independent practice). Notably, in order to enroll in a graduate program to become an advanced practice psychiatric nurse, an individual must first be a registered nurse with a bachelor's degree in nursing. The other provider types in this report do not have equivalent requirements for specific undergraduate degrees or for prior licensing. Table 1 provides a brief description of each graduate degree, including requirements such as a field experience or a dissertation. The table also indicates the amount of time typically required to complete the degree. In some cases, individuals may complete the degree in less time (e.g., by participating in an accelerated program) or more time (e.g., by attending school part-time or taking longer to complete a dissertation). For most provider types discussed in this report, licensure for independent practice requires a period of postgraduate supervised practice. This period of supervised practice is distinct from the practicum or internship experiences required to obtain a degree. An example of such supervised practice is the residency required for physicians to become psychiatrists. State licensing boards generally require a passing score on an exam offered by a national body (e.g., the Association of Social Work Boards), although some state licensing boards may offer their own exams in addition to or in lieu of the national exam. In some cases, individuals applying for licensure may have a choice of exams that meet the licensure requirement. The timing of the exam may vary by state; that is, some states may allow individuals to take the exam immediately upon completing the degree requirements, while other states may require individuals to have completed a portion (or all) of the supervised practice requirement prior to taking the exam. The scope of practice for each provider type is established at the state level by state statute, regulation, or guidance. Table 2 highlights elements within scope of practice that involve diagnosing and treating mental illness. The scope of practice for most provider types includes other activities, such as preventive care, case management, and consultation with other providers. The scope of practice described in the table reflects what is generally true in most states. For example, prescribing medication is included in the scope of practice for advanced practice psychiatric nurses, a provider type that comprises both nurse practitioners (allowed to prescribe medication in all states) and clinical nurse specialists (allowed to prescribe medication in only some states). Access to mental health care depends, in part, on the number of practicing mental health providers relative to the population; however, such information is not systematically available for analysis. Workforce data are collected and reported by multiple sources. However, each source has its limitations in assessing the overall size of the workforce. HRSA designates Mental Health Professional Shortage Areas (MHPSAs) based on the ratios of psychiatrists, APPNs, clinical psychologists, clinical social workers, and MFTs to the population; however, HRSA does not systematically collect the data used to designate MHPSAs (see text box). HRSA's Area Health Resource Files (AHRF) compiles health-related data from various sources. The AHRF draws much of its health workforce data from datasets created by--and more readily available from--the Department of Labor. Some other sources of health workforce data in the AHRF are updated infrequently, if at all. For example, the 2016-2017 ARHF includes the number of psychologists from a 2009 analysis by a private research center. Thus, other sources of mental health workforce size estimates may be more useful than the AHRF to policymakers. National workforce data--which are not limited to the health care workforce--are generally collected by the Bureau of Labor Statistics (BLS) within the Department of Labor. Each data source has important limitations, as described below. The Occupational Employment Statistics (OES) program produces employment estimates for more than 800 occupations based on a semiannual survey of establishments selected by the BLS from lists maintained by State Workforce Agencies for unemployment insurance purposes. An important limitation of OES data is that it excludes the self-employed. The OES includes specific categories for psychiatrists and MFTs. Within the field of psychology, the OES has a subcategory for "clinical, counseling, and school psychologists." Within the field of social work, the OES has a subcategory for "mental health and substance abuse social workers." The OES does not distinguish APPNs from the broad category of nurse practitioners. The Current Population Survey (CPS) provides information about employed persons by occupation based on a monthly household survey. The CPS does not distinguish licensed clinical psychologists from other psychologists, mental health social workers from other social workers, psychiatrists from other physicians, APPNs from other nurse practitioners, or MFTs from counselors. Thus the CPS overestimates the size of the workforce in these professions in such cases where it provides an estimate at all. The Occupational Outlook Handbook (OOH) provides information about occupations based on the National Employment Matrix, which combines employment data from both the OES and the CPS. Like the OES, the OOH includes specific categories for psychiatrists and MFTs and subcategories within psychology (clinical, counseling, and school psychologists) and social work (mental health and substance abuse social workers). The OOH does not distinguish APPNs from the broad category of nurse practitioners. Additional sources of workforce data may be available on a case-by-case basis from professional associations or other organizations. Various estimates of each mental health profession are provided below, along with their limitations. Where comparable data are available for the various disciplines, estimates show that clinical social workers are the most abundant of the mental health professions in this report. The OES estimates 112,040 mental health and substance abuse social workers in 2017, excluding those who are self-employed. The workforce size of mental health and substance abuse social workers decreased from 2016 to 2017 by 1.8%. The OOH estimates 123,900 mental health and substance abuse social workers in 2016. The CPS does not distinguish mental health social workers from school social workers, medical social workers, or other social workers. Recent estimates of the number of mental health social workers are not publicly available from membership organizations or licensing boards. The number of clinical psychologists is generally estimated to be less than that of social workers and more than that of other disciplines included in this report. The American Psychological Association (APA) identified "100,305 unique licensed psychologists with doctoral degrees" by collecting, standardizing, merging, and de-duplicating lists from the licensing boards of the 50 states and the District of Columbia in 2015. Given that not all licensed psychologists are currently practicing in patient care, APA's number is likely the upper limit for licensed psychologists in the mental health workforce in 2015. This is not a data source that is regularly updated and made publicly available. Estimates that are regularly updated are all greater than the APA estimate. The OES estimates 108,060 "clinical, counseling, and school psychologists" in 2017, excluding those who are self-employed and including school psychologists (whose licensure is different than that of clinical or counseling psychologists). The workforce size of clinical, counseling, and school psychologists increased from 2016 to 2017 by .07%. The CPS estimates 187,000 psychologists in 2017, including school psychologists, industrial/organizational psychologists, and others. The OOH estimates 147,500 "clinical, counseling, and school psychologists" in 2016. Estimates of the number of MFTs are substantially lower than those of social workers or psychologists and higher than those of psychiatrists or APPNs. The OES estimates 42,880 MFTs in 2017, excluding those who are self-employed. The workforce size of MFTs increased from 2016 to 2017 by 13.8%. The OOH estimates 41,500 MFTs in 2016, including those who are self-employed. Recent estimates of the number of MFTs are not publicly available from the CPS, membership organizations, or licensing boards. Estimates show that there are fewer psychiatrists than clinical social workers, psychologists, or MFTs; however, psychiatrists outnumber APPNs. The OES estimates 25,520 psychiatrists in 2017, excluding those who are self-employed. The workforce size of psychiatrists increased from 2016 to 2017 by 2.7%. The OOH estimates 27,500 psychiatrists in 2016, including those who are self-employed. The American Medical Association (AMA), a physician membership organization, gathers physician workforce information in the Physician Masterfile. Using the Physician Masterfile, the AMA estimated 37,938 self-designated psychiatrists in 2013 (the most recent data publicly available). The CPS does not have publicly available estimates of the psychiatrist workforce size. The number of APPNs is generally found to be less than those of other mental health providers in this report. The American Nurses Credentialing Center--a subsidiary of the American Nurses Association that certifies specific practice areas--estimates 15,911 APPNs in 2016, based on certification data. The OES, OOH, and CPS do not distinguish between APPNs and other advanced practice nurses. Just as access to mental health care providers depends partly on the size of the mental health workforce, the cost of mental health care depends partly on the wages paid to mental health providers. Table 3 presents mean and median annual wages from the BLS. These wage data are widely used because of their large sample size, broad geographic reach, and the comparable methodology used to collect data across occupations. Information from BLS is likely to either over- or understate wages for some mental health providers; the data are based on a survey that excludes self-employed workers (i.e., those in private practice), who may have different incomes. For example, for both clinical psychologists and clinical social workers, the categories used by the BLS include individuals who may earn substantially less than those who meet the HRSA definition of the provider type. The wage estimates for clinical psychologists are based on a category that includes school psychologists, who do not have to meet the same licensure requirements as HRSA-defined clinical psychologists and thus might receive lower wages. Similarly, the wage estimates for clinical social workers are based on a category that includes individuals who are not licensed for independent practice and who also might earn less. Despite their limitations, the BLS data are able to illuminate the relative wages of each provider type as outlined in Table 3 . Psychiatrists are the relative highest earners, followed by advanced practice psychiatric nurses and clinical psychologists. Marriage and family therapists generally earn more than clinical social workers. Understanding the mental health workforce may help policymakers address a range of potential policy issues related to mental health care, including its quality, access, and cost. An understanding of typical licensure requirements and scopes of practice may help policymakers determine how to direct federal policy initiatives focused on enhancing the quality of mental health care such as those related to training mental health providers. If, for example, training new providers quickly is a priority, initiatives may focus on training additional providers who can be licensed with a master's degree, rather than a doctoral degree. Initiatives may focus on training providers who can prescribe medication if the need is greater for medication than for psychosocial interventions. Going beyond the provider types discussed in this report, if a priority is to expand the breadth of the mental health workforce, policymakers might also consider federal training directed toward initiatives that focus on paraprofessionals who do not require extensive training or toward primary care professionals who do not specialize in mental health but may provide care for individuals with mental illness. Increasing the breadth of the mental health workforce may also increase its overall size. Another way policymakers may influence the size of the mental health workforce (and thus access to mental health services) is through the provision or expansion of federal programs. For example, the federal government may provide grants to establish or expand training programs for mental health providers. The federal government may also provide incentives such as loan repayment or loan forgiveness to encourage individuals to enter mental health occupations, which are projected to grow faster than the overall workforce. Policymakers may consider strategies to direct people into these high growth fields as part of larger labor force policy considerations. Initiatives may be targeted to certain provider types or to certain locations (e.g., MHPSAs). Policymakers may also wish to consider the relative wages of different provider types, particularly when addressing domains within which the federal government employs mental health providers. For instance, agencies which employ these mental health professionals include the Department of Defense, the Veterans Health Administration (within the Department of Veterans Affairs), the Bureau of Prisons (within the Department of Justice), and the Indian Health Service (within HHS), among other agencies. The federal government is the largest employer of some provider types, such as clinical psychologists and social workers. As such, the cost of employing different provider types--as well as their scopes of practice--may be a consideration in determining staffing priorities. Appendix A. Additional Resources Below are resources for additional information about each mental health provider type, including national associations of state boards, professional associations, accrediting organizations for educational programs, and other relevant organizations. In some cases, a single organization may serve multiple roles (e.g., a professional association may also accredit educational programs). Psychiatrists American Academy of Addiction Psychiatry (AAAP): http://www.aaap.org/ American Academy of Child & Adolescent Psychiatry (AACAP): http://www.aacap.org/ American Academy of Clinical Psychiatrists (AACP): http://www.aacp.com/ American Board of Medical Specialties (ABMS): http://www.abms.org/ American Board of Psychiatry and Neurology (ABPN): http://www.abpn.com/ American Psychiatric Association (APA): http://www.psychiatry.org/ National Board of Osteopathic Examiners: http://www.nbome.org/ Psychologists American Psychological Association (APA): http://www.apa.org/ Association of State and Provincial Psychology Boards (ASPPB): http://www.asppb.net/ Social Workers Association of Social Work Boards (ASWB): http://www.aswb.org/ Council on Social Work Education (CSWE): http://www.cswe.org National Association of Social Workers (NASW): http://www.socialworkers.org/ Social Work Policy Institute (SWPI): http://www.socialworkpolicy.org/ Advanced Practice Psychiatric Nurses American Academy of Nurse Practitioners (AANP): http://www.aanp.org/ American Nurses Credentialing Center (ANCC): http://www.nursecredentialing.org/ American Psychiatric Nurses Association (APNA): http://www.apna.org/ National Association of Clinical Nurse Specialists (NACNS): http://www.nacns.org/ National Council of State Boards of Nursing (NCSBN): http://www.ncsbn.org/ Marriage and Family Therapists American Association for Marriage and Family Therapy (AAMFT): http://www.aamft.org/ Association of Marital and Family Therapy Regulatory Boards (AMFTRB): http://www.amftrb.org/

Summary:
Congress has held hearings and some Members have introduced legislation addressing the interrelated topics of the quality of mental health care, access to mental health care, and the cost of mental health care. The mental health workforce is a key component of each of these topics. The quality of mental health care depends partially on the skills of the people providing the care. Access to mental health care relies on, among other things, the number of appropriately skilled providers available to provide care. The cost of mental health care depends in part on the wages of the people providing care. Thus an understanding of the mental health workforce may be helpful in crafting policy and conducting oversight. This report aims to provide such an understanding as a foundation for further discussion of mental health policy. No consensus exists on which provider types make up the mental health workforce. This report focuses on the five provider types identified by the Health Resources and Services Administration (HRSA) within the Department of Health and Human Services (HHS) as mental health providers: clinical social workers, clinical psychologists, marriage and family therapists, psychiatrists, and advanced practice psychiatric nurses. The HRSA definition of the mental health workforce is limited to highly trained (e.g., graduate degree) professionals; however, this workforce may be defined more broadly elsewhere. For example, the Substance Abuse and Mental Health Services Administration (SAMHSA) definition of the mental health workforce includes mental health counselors and paraprofessionals (e.g., case managers). An understanding of typical licensure requirements and scopes of practice may help policymakers determine how to focus policy initiatives aimed at increasing the quality of the mental health workforce. Most of the regulation of the mental health workforce occurs at the state level because states are responsible for licensing providers and defining their scope of practice. Although state licensure requirements vary widely across provider types, the scopes of practice converge into provider types that generally can prescribe medication (psychiatrists and advanced practice psychiatric nurses) and provider types that generally cannot prescribe medication (clinical psychologists, clinical social workers, and marriage and family therapists). The mental health provider types can all provide psychosocial interventions (e.g., talk therapy). Administration and interpretation of psychological tests is generally the province of clinical psychologists. Access to mental health care depends in part on the number of mental health providers overall and the number of specific types of providers. Clinical social workers are generally the most plentiful mental health provider type, followed by clinical psychologists, who substantially outnumber marriage and family therapists. While less abundant than the three aforementioned provider types, psychiatrists outnumber advanced practice psychiatric nurses. Policymakers may influence the size of the mental health workforce through a number of health workforce training programs. Policymakers may assess the relative wages of different provider types, particularly when addressing policy areas where the federal government employs mental health providers or pays for their services through government programs such as Medicare. Psychiatrists are typically the highest earners, followed by advanced practice psychiatric nurses and clinical psychologists. Marriage and family therapists earn more than clinical social workers. The relative costs of employing different provider types may be a consideration for federal agencies that employ mental health providers.