Weaving a Safety Net
Columbia Nursing is strengthening the mental health care system in six ways.
Three years into the pandemic, the threat of COVID-19 itself may be receding, but the nation’s mental health care system is being strained as never before. Substance misuse, depression, overdose deaths, and gun violence are all on the rise. Thirty-seven percent of high school students reported poor mental health during the pandemic, and 44 percent said they felt sad or hopeless in the previous year, according to a 2021 survey by the Centers for Disease Control and Prevention (CDC). And that’s on top of the fact that, according a 2009-2019 CDC report, mental health problems and suicidal behaviors among youth had already been increasing before the onset of the pandemic.
Among the hardest hit by the pandemic’s mental health effects were youth from minoritized groups and those with disabilities. Young people from rural areas or low income or immigrant households, as well as those involved with the child welfare or juvenile justice systems, were also more severely affected.
COVID affected adults, too. The incidence of depression and anxiety in this country doubled in recent years; before the pandemic, one in 10 U.S. adults reported anxiety or depression, while now about one in five do. Globally, the World Health Organization estimates that rates of depression and anxiety went up 25 percent.
In more hopeful news, the pandemic has also resulted in increased awareness regarding the centrality of mental health to overall health and wellness. President Biden has made tackling the nation’s mental health crisis a priority, highlighting youth mental health, suicide among veterans, and the opioid crisis in his 2022 and 2023 State of the Union addresses. This heightened awareness has had several benefits, including reducing the stigma often associated with mental illness and encouraging more people to seek mental health care. Funding for such care has also begun to rise, especially for programs targeting children and adolescents. The White House recently announced that the Department of Education will distribute more than $280 million in new grants to support school-based mental health care.
However,there are still far too few mental health clinicians to meet the growing need. And accessing mental health care is more difficult for historically marginalized groups, who also have worse mental health outcomes than whites. Just one-third of Black or Hispanic people with mental illness receive treatment, compared to 43 percent of white patients.
“A ONE-STOP SHOP”
Enter the psychiatric-mental health (PMH) nurse. Most PMH nurses are registered nurses (PMHRNs), with 109,000 certified in the U.S., according
to a 2020-2021 workforce survey by the American Psychiatric Nurses Association (APNA). Some PMH nurses have training at the master’s or doctoral
level; this cohort, known as advanced practice RNs (APRNs), grew from 13,000 in 2013 to 26,000 in 2020. (The APRN cohort includes PMH nurse practitioners [PMHNPs] and PMH certified nurse specialists, who have equivalent qualifications.)
Fortunately, “more people are interested in becoming psychiatric mental health NPs,” says Laura Kelly, PhD, who directs Columbia Nursing’s PMHNP program. “I think our visibility is increasing as more funding becomes available to mental health.”
Kelly notes that PMHNPs have been serving mental health patients in the community for decades. They are qualified to provide mental health care across the life span, to individuals and to families, although many choose to specialize in a particular population. PMHNPs’ scope of practice embraces delivering education; offering psychotherapy; diagnosing, treating, and managing chronic and acute illnesses; prescribing and managing psychiatric medications; making referrals; ordering diagnostic tests; and more.
“We really function as a one-stop shop,” says Beth Maletz, DNP, an assistant professor in Columbia Nursing’s PMHNP program. “It’s just really nice to be able to do all of that for our patients.”
Says MDE-DNP student Michelle Charles MS ’21, who came to nursing from social work: “Nursing is so special because both the psychosocial and the physiological are really evenly weighted in its foundation.”
Here are six ways that Columbia nurses are helping to build a stronger mental health safety net.
1. Educating more PMHNPs
Once Columbia Nursing’s smallest educational program, the PMHNP track is now its second-largest. Record numbers of applicants are aspiring to fill the program’s 35 spots, with upwards of 100 applicants in recent years, Kelly notes. “The more people we can educate into the workforce, the more patients will have access to mental health care,” she says.
Over half a million new PMH nurses would need to be hired to provide “merely adequate access” to mental health care in the U.S., according to the federal Substance Abuse and Mental Health Administration (SAMSHA). Nurse leaders and health policy experts agree that expanding the field, and extending full scope of practice to PMHNPs nationwide, will be essential to achieving the equitable delivery of mental health care.
One factor limiting this expansion is a shortage of practitioners in the field available to supervise students on their clinical rotations, says Latisha Hanson, DNP ’15, an assistant professor of nursing who teaches both MDE and DNP students. Building a robust pipeline from schools to the workforce, Hanson says, will require more nurses to consider becoming preceptors or clinical instructors.
“We really do feel like we are educating and training the next generation of psych NPs to go out into the world and fill this space that historically hasn’t been filled,” Maletz says. “We’re very focused on social justice, we’re very focused on health equity, and we’re training our students to look at everything through those lenses.”
2. Intervening early
Integrating mental health care with primary care and promoting positive parenting among families with young children at risk for developmental, emotional, or behavioral difficulties can help prevent or mitigate serious emotional or behavioral problems later on, says Maletz, who did her doctoral work in this area.
In January 2020, she launched the Maternal and Child Integrated Mental Health Program (MACIMP) at NewYork-Presbyterian Hospital, with four physicians, a psychologist, and a small grant. The program has “exploded,” she says. “We’ve gotten a lot of additional funding and resources around maternal and early childhood mental health.”
MAC-IMP now includes a team that ensures families’ needs are being met from a social determinants perspective, a doula program, and behavioral health specialists who work with women during their pregnancy and, after they give birth, with the mother and child until the child’s third birthday.
Maletz is currently developing a program to identify parents with risk factors or behavioral health needs before their child is born, so they can begin treatment during pregnancy. The goal of this program, and of MAC-IMP overall, is to prevent intergenerational trauma and prepare expectant mothers for the experience of being a parent, she says. “We focus on attachment and bonding, we focus on breastfeeding, we focus on recovery after birth.” Later, the focus shifts to parenting, child development, toilet training, and the like.
The team works with all families the program serves but uses risk stratification to identify those most in need and ensure that they receive the most resources.
To date, Maletz says, her team has helped more than 1,000 families with its early childhood program alone, an evidence-based national model called HealthySteps.
“I have learned that regardless of what the mental health issue is, parents and caregivers are the best people to take care of their own children,” Maletz says. “And if we give them what they need, their children are going to be much better off.”
3. Advancing telehealth
Psychotherapy is highly effective (in some cases accompanied by medication) for treating depression, anxiety, post-traumatic stress disorder (PTSD), and a host of other mental health issues. And the widespread adoption of telehealth during the pandemic has made psychotherapy far more accessible and convenient for many patients.
Maletz now relies almost entirely on telehealth to provide psychiatric care to children and adolescents and their families from a pediatric clinic serving Washington Heights and the Bronx. “Telehealth has definitely increased access enormously for my patient population,” she says. “The families prefer this. They love that they don’t have to schlep to the clinic, and kids don’t have to miss school and families don’t have to miss work.”
Teletherapy is especially suited to adolescents, she notes. “They do everything on their phone, so they just love it. They can click a button and see me, get what they need, and then go hang out with their friends.”
Working by phone also allows clinicians to see their patients in a more natural, comfortable setting than a typical clinic or doctor’s office, Maletz adds. “They’re much better able to talk about what’s going on for them, what they’ve been experiencing, what their symptoms are.”
A drawback of telemedicine, Hanson notes, is that group therapy—a great way to scale up access to mental health care—doesn’t work very well on Zoom. And even for one-on-one consultations, periodic in-person visits are still essential, she adds, such as for annual checkups.
Says Kelly: “It would be doing a disservice to our students if we didn’t provide them with a platform for tele-psychiatry, because they’re going to be doing it when they graduate. This is a modality in which the students have to become proficient. It will never go away.”
4. Meeting patients where they are
Increasingly, PMHNPs are working not in hospitals but within primary care settings, community-based organizations, and schools to provide more easily accessible mental health care to those most in need. Integrating mental health care with primary care, in a patient-centered medical home, “has enormously removed the stigma and increased access for patients who seek mental health care,” Maletz says.
She believes more and more mental health treatment will be provided in community settings. “And it really is psych-mental health NPs who are doing that work,” she adds.
5. Using a trauma-informed perspective
In 2018, in recognition of the huge toll of trauma on health, SAMSHA’s Center for Mental Health Services (CMHS) launched the Interagency Task Force for Trauma-Informed Care (TIC Task Force) to investigate best practices in care for children and youth and ways to improve the federal government’s response to families affected by trauma.
“A trauma-informed approach to care acknowledges that health care organizations and care teams need to have a complete picture of a patient’s life situation—past and present—in order to provide effective health care services with a healing orientation,” the TIC Task Force website states.
Columbia Nursing has a $1.9 million grant from the Health Resources and Services Administration’s Behavioral Health Workforce Education and Training Program to educate PMHNP students and occupational therapy students on interprofessional trauma-informed care. Students in the program are currently running trauma-informed mindfulness groups at a school in Brooklyn for students in kindergarten through eighth grade.
Latisha Hanson has found the trauma-informed approach useful in the nursing classroom as well. She conducts a check-in with her students before she does anything else, to see how they’re doing. Those with a history of trauma may need more space to prepare themselves to learn about the effects of trauma, she adds, but they can still learn. And by using the trauma-informed approach with students, Hanson notes, preceptors are also modeling it for them.
“I try to take what’s going on in society into the classroom,” adds Hanson. For example, she makes time for discussion of traumatic events in the news and uses those discussions as an opportunity to teach and practice simple grounding exercises. “We have to be able to get through our own feelings.
“The students are so motivated,” Hanson adds. “They see the value of trying to reduce some of the sequelae that result from trauma and untreated mental illness so they can help people to be the best selves they can be.”
6. Delivering psychotherapy
“The philosophy of our program is that psych NPs are therapists first, that’s what differentiates us,” says Kelly. “Most students who come here want to be therapists.”
This was a major draw for Alyssa Lee, who started her MDE-DNP in June 2020. “The role of therapy —learning different types, between family, individual, and group—is something that is given its space within the program,” she says. “Not all psych NP programs really understand or focus on the role that therapy has. And that was something that I felt really passionately about because I have seen therapy be so powerful.”
Her classmate Jordan Arbelaez MS ’21 also chose Columbia Nursing for its emphasis on psychotherapy. “I have been seeing psychotherapy clients now for over a year, and I don’t plan to ever stop,” she says. “There is so much evidence supporting improved long-term outcomes with psychotherapy as opposed to medication alone.”
For example, in Arbelaez’s first-year scholarly writing course, she reviewed the medical literature on two long-term treatments for PTSD: selective serotonin reuptake inhibitors (SSRIs) and eye movement desensitization and reprocessing (EMDR) therapy. “I was so amazed by the evidence supporting EMDR therapy as superior to SSRIs for long-term relief of PTSD,” says Arbelaez, “that I became certified as an EMDR therapist through EMDRIA,” a professional organization devoted to the therapy. “I think it’s important PMHNPs incorporate therapy into practice in order to best serve our patients.”
This article originally appeared in the Spring 2023 issue of Columbia Nursing Magazine.