More Psychologists, More Problems? The Paradox of Mental Health Workforce Expansion

A new study published in the International Journal of Mental Health and Addiction challenges the common belief that expanding the mental health workforce alone will improve mental health outcomes.

The research was conducted by a team of experts from the Centre for Health Management and Policy Research at Shandong University, China, including Yifan Chen, Yunxi Zhong, Qixiu Li, Xiaoying Su, and Long Sun. Additionally, Xiao Li from Genentech, Inc., a pharmaceutical research company in South San Francisco, USA, contributed to the study.

“The study highlights the need to scale up investment in mental health, formulate equity-oriented mental health workforce policies, and allocate human resources appropriately to achieve effective universal health coverage and mental health transformation,” the authors write.

“Together with increasing the mental health workforce, countries and territories should consider reshaping environments, increasing mental capital, and enriching mental health care, particularly in areas with high workforce density or advanced social development.”

The study reveals significant differences in the availability of psychologists across countries, with more psychologists concentrated in wealthier, more developed areas. Over the past 30 years, this gap has widened. Increasing the number of psychologists may reduce mental health issues in less developed countries, but the effect is less significant in wealthier, more developed regions, supporting the “Vulnerability Paradox.” This raises questions about the effectiveness of current global mental health strategies and emphasizes the need for community-based approaches addressing social determinants of mental health.

The Movement for Global Mental Health (MGMH) has focused on closing the “treatment gap” for mental health conditions worldwide, noting that low- and middle-income countries face a severe shortage of mental health professionals, hindering effective treatment. Interestingly, research shows that even countries with more mental health resources, like the USA, Australia, and Western Europe, still have a high burden of mental disorders.

This “vulnerability paradox” suggests that simply increasing the number of mental health professionals doesn’t always lead to better outcomes. The relationship between the mental health workforce and mental disorder burden varies with social development levels, highlighting a complex interaction that needs further exploration.

The study analyzed data on the mental health workforce, socio-demographic index (SDI), and mental disorder DALY rates from 204 countries from 1990 to 2019. The data was sourced from the Global Burden of Disease database, United Nations Statistics, and Our World in Data, including demographic and economic factors like population density and GDP per capita. The mental health workforce was measured by the density of psychologists, categorized by SDI levels, and the outcome variable was the DALY rates for mental disorders.

Researchers used statistical tools to evaluate the trends and inequalities in psychologist density over time. The slope index (SI) and concentration index (CCI) measured absolute and relative inequalities, showing how psychologists are distributed relative to countries’ SDI levels. The generalized additive mixed model (GAMM) helped assess the complex relationships between psychologist density, SDI, and mental disorder DALY rates, considering non-linear associations and adjusting for various factors.

The study found that the number of psychologists varies widely across different countries. In 2019, Bermuda had the highest number of psychologists, with nearly 30 per 10,000 people, while Somalia and Ethiopia had fewer than one psychologist per 10,000 people. Most countries, except for Zimbabwe, saw an increase in psychologists over the years. Generally, wealthier countries with better social conditions had more psychologists, highlighting significant global inequalities.

From 1990 to 2019, the gap between countries with many psychologists and those with few widened. This means that richer countries have become even more concentrated with psychologists, leaving poorer countries further behind. The study found that having more psychologists is linked to better mental health outcomes, but this benefit is less noticeable in wealthier countries.

When looking at different groups of countries based on their development levels, the study showed that increasing the number of psychologists helps reduce mental health issues, especially in less developed areas. In more developed areas, the positive impact is still there but not as strong.

The findings suggest that while having more psychologists generally improves mental health, other factors also play a crucial role, particularly in wealthier countries. In addition to increasing the number of mental health professionals, countries should also focus on improving the social and environmental factors that influence mental health, especially in developed areas where current strategies are less effective.

The study has several potential limitations. Firstly, since it uses national data, the findings cannot be applied to smaller community or individual levels. Secondly, the study relies on predictive models to estimate missing data for certain years or regions, which means the quality of this data depends on the accuracy of these models. This is especially true for low-development areas where data might be less accurate.

Additionally, the study focused solely on the number of psychologists, which may not capture the complete picture of the mental health workforce. If only professionals are considered, there might be an undercount of mental health workers, neglecting those who practice traditional, spiritual, and indigenous healing methods. This could lead to an incomplete understanding of the mental health resources available in different regions.

The authors contend that developed countries need more than just mental health workers; they need to transform mental healthcare and shape environments to achieve fair and universal mental health care. This means global policies should not use a “one-size-fits-all” approach but instead focus on targeted efforts and resource transfers to ensure fair and efficient allocation.

 

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Chen, Y., Li, X., Zhong, Y. et al. The Vulnerability Paradox in Global Mental Health: Psychologist Density, Social Development, and the Disease Burden of Mental Disorder. Int J Ment Health Addiction (2024). https://doi.org/10.1007/s11469-024-01331-y (Link)