Low pay, fewer advancement opportunities and an excessive workload rank as the top reasons the military services fail to recruit and retain psychiatrists, psychologists and other mental health providers, according to a new Defense Department report.

With more than 50 percent of psychiatrists nationwide able to run cash-only practices, with many making six-figure salaries, the Army, Navy and Air Force lack a competitive advantage when it comes to paying civilians and drawing military providers, as noted in a report Nov. 29 to Congress.

Add in a slow hiring process, onerous paperwork and little say in assignments — particularly overseas — and the services can’t keep up with demand.

The challenges are a threat to morale, and subsequently, retention, the report states.

“When combined with the Defense Health Agency’s access-to-care standards, this reality creates a demoralizing situation in which providers can perform initial behavioral health evaluation but are subsequently unable to provide therapeutic interventions,” the report noted.

Providers who wear uniforms also face additional burdens that prompt many to leave, including frequent changes of duty station and low opportunities for advancement.

The Army promotion system “validates and rewards leadership while often clinical career pathways,’ which can force effective providers out of the service, the report stated.

In the Navy, psychologists who reach the rank of lieutenant rarely make the next rank “due to a preponderance of operational billets where the psychologist is not being ranked against peers.”

And while the Air Force is exploring new residency training and recruiting platforms for developing therapists and mental health nurse practitioners, its efforts to recruit already qualified psychologists have not “met with much success,” the report said. Losses of psychiatrists due to separation and retirement from the Air Force also are outpacing the training pipeline and recruiting.

The demand for mental health services has risen across the United States in the past decade as the number of providers is has not kept pace and is barely holding steady. The Health Resources and Services Administration projects a shortfall of 250,000 providers by 2025.

And some geographic regions are harder hit by the mental health provider shortage. In these areas, the Defense Department faces even more difficult challenges hiring and retaining an adequate number of personnel.

The report does not note how many mental health professionals may be needed by the services, nor does it provide the number of jobs that are unfilled. In May, Navy Capt. Mike Colston, the Defense Department’s director of mental health policy and oversight, told members of the House Armed Services Personnel Subcommittee that roughly 10,000 mental health providers in behavioral health clinics, within primary care and embedded in units.

But according to the report, the number is far fewer: the estimate for 2020 is 6,627 providers, up from 6,599 in 2018. That’s roughly one provider for every 462 active-duty and active-duty family members — not including retirees and their family members, many of whom have access to mental health services at military treatment facilities.

According to the report, the Air Force will face the biggest shortage in the next year, expecting to lose nearly 600 mental health providers, down to 1,011 in 2020, from 1,601 in 2018.

The Army and Navy will see increases: from 3,108 in 2018 to roughly 3,134 in 2020 for the Army, and from 1,601 in 2018 to 1,700 for the Navy.

The largest gains of mental health personnel are likely to be seen in the Washington, D.C., metro region, according to the report. The National Capital Area, as its called, had 289 civilian and uniformed providers in 2018; in 2020, it is expected to have 782.

The report noted that the D.C. area is one of the most challenging in the country to hire mental health providers; more than 80 percent of psychiatrists, psychologists and license clinical social workers do not take insurance, operating on a cash-only basis.

Patricia Kime is a senior writer covering military and veterans health care, medicine and personnel issues.

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