This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.

Even as mental health issues have risen worldwide, Michigan has fallen behind on having enough health professionals to address that trend. According to National Alliance on Mental Illness (NAMI) data, there were 421,000 Michiganders who did not receive needed mental health care in 2021, but only 38.4% cited cost as the reason. A Kaiser Family Foundation analysis illustrates one of the other key reasons people aren't getting the care they need. That study finds that more than four million Michiganders live in communities with a shortage of mental health professionals, ranking fifth worst in the nation, behind Texas, California, Alaska, and Missouri.

"There's a systemic shortage. We don't have enough providers to meet the needs of the population. The shortage has progressively gotten worse over the last five or 10 years. And we're feeling the impact even more due to COVID," says Timothy Michling, research associate in health affairs at the Citizens Research Council of Michigan and author of a report entitled "Michigan Falls Short on Mental Health Services." "When we look at projections going forward, we see the gap between demand and supply of providers widening. If we don't address the issue now, it's only going to get worse in the future."

According to Michling, this shortage spans the mental health professions, from direct caregivers to master's-level therapists to social workers to psychiatrists to psychologists. Many Michigan counties have no psychiatrists, particularly for children and adolescents.

"Mental health underpins our wellness as a society. We see much worse outcomes in a variety of health conditions when you have an untreated mental health disorder. This affects our economy and our society at large," Michling says. "Students are not able to do as well in school if they have an undiagnosed or untreated mental health condition. And that follows children into adulthood. It affects their career readiness. It affects our rates of homelessness, our rates of unemployment and workforce participation."

Filling the void for tribal communities

Effects of the mental health professional shortage vary by geographic region in Michigan. Six Upper Peninsula counties and nine Lower Peninsula counties have no psychiatrists, and three UP counties and seven Lower Peninsula counties have neither psychiatrists or psychologists. Michelle Schulte, maternal infant child health division director for the Inter-Tribal Council of Michigan (ITCMI), works with Northern Michigan tribal communities located in some of these areas of need.
Michelle Schulte.
"The shortage of mental health professionals is impacting people in our communities in a very bad way," Schulte says. "We have long waiting lists … People who have needs can't get in. In our rural areas, especially the UP, many people have to travel two to four hours to get the kind of care that they need. Some tribal communities have a limited contract with a local psychiatrist or psychologist that comes in maybe once a month and sees everybody on that same day. If you miss your appointment or can't make it on that day, you're stuck."

Schulte and her ITCMI colleagues have collaborated with a wide range of partners to create projects and programs that shore up the lack of mental health services, especially for children and young families. MIchigan Medicine's Michigan Child Collaborative Care program provides mental health services via telehealth. The Michigan Public Health Institute and Michigan Association for Infant Mental Health programs train early childhood teachers to address children's mental health in Head Start programs and tribal schools, and to equip designated child behavior specialists from within the community to support families. 

"We're seeing children who have a high influx of behaviors that our early childhood providers have never had to deal with before or feel ill-equipped to deal with," Schulte says. "A child may have disruptions at home, … may not have slept well, may not have been bathed, or may feel run down. How do we address it in a way that the child gets what they need, as far as nurturing attention or care?"

ITCMI social media campaigns enlist aunts, uncles, and grandparents to play traditional cultural roles in raising children within extended families. An ITCMI focus group with tribal elders explored Anishinaabe words for resiliency, producing rich definitions that strengthen that concept in community. 

"Our goal is to support healthy development and resiliency in children," Schulte says. 

NAMI Michigan a first responder for many

Kevin Fischer, executive director of NAMI's Michigan chapter, agrees that the state is experiencing a dire shortage of mental health professionals. That may be one reason that NAMI affiliates across the country have seen requests for help increase between 80% and 100% over the last year. The nature of the calls for help has changed, as well. More people are calling with an urgent need for services. NAMI's education and support programs also are seeing huge increases in enrollment.

"People are calling to get a better understanding of what's going on, what a mental health diagnosis means," Fischer says. "For example, they ask, 'What is schizophrenia? What does bipolar mean?' They may have a family member and want to better understand how they can help them."
Kevin Fischer.
NAMI Michigan's peer-support volunteers help the nonprofit meet this increasing need. These peers have lived experience of mental illness. That experience may be helpful to a person initially diagnosed with a mental illness, who may feel uncomfortable talking to friends or family members about it.

"They really want to talk to somebody who's walked in their shoes already, to get an understanding of what their recovery process would look like," Fischer says. "Peer supports have become tremendously valuable."

Fischer notes that unless more mental health professionals enter the field, Michigan communities will be ill prepared for increasing demand for mental health services. For example, from 1999 to 2019, suicide rates have increased in the general population by 35%. Other groups have seen even more severe increases. Among Black male adolescents, suicide attempts increased by nearly 80% between 1991 and 2019.

"We're seeing another significant uptick in needs for mental health services among young people because of social distancing and closing the schools," Fischer says. "There's a significant increase in mild to moderate mental illness — depression, anxiety, some self-harm like cutting. Across the board, there's been a significant increase."

More strategies for increasing the ranks

Fischer notes that the surge in telehealth usage has helped address the shortage of mental health professionals, especially when COVID-19 limited face-to-face health care visits. While virtual video calls are not the answer for every person living with mental illness, the modality has had surprising success. Another strategy that could help relieve the shortage is better equipping primary care providers to offer mental health services.

"We're in this age now where we're talking about integrated health care. Our primary care physicians really should be our first responders for behavioral health care," Fischer says. "They are able to diagnose and prescribe medication for people who are experiencing mild to moderate mental health diagnoses, or refer them to a psychiatrist or psychologist if they think something more serious is going on, like schizophrenia or bipolar disorder. But that's not the norm."

Michling concurs. However, even though primary care physicians may have received mental health care training in medical school, many are not comfortable — or not willing — to tackle mental health issues during office visits. Additional options to address the shortage include policy changes that allow nurse practitioners to have a wider scope of practice, school loan forgiveness for college graduates entering behavioral health care fields, and better insurance reimbursement levels for behavioral health services.

"We also want to look at ways to incentivize people to stay in the field so we don't have high rates of atrophy and people leaving the field for other professions. That requires research on why folks are leaving," Michling says. "Recruitment efforts at the undergraduate or high school level could make a really clear talent pipeline and career trajectory for folks to get into various behavioral health careers. Beyond that, providing grants to help hospital emergency departments deal with psychiatric or other mental health emergencies, or supplemental training for physicians, nurses, and other emergency department personnel, could make them better equipped to deal with what we're seeing."

While finding ways to increase the ranks of mental health professionals is essential, Michling feels it is even more important to address the root causes of growing mental illness among Michiganders.

"Much in the way that we treat chronic disease, we want to focus our public health resources on strategies to deal with stress, improved nutrition, improved sleep, mitigating the community-level factors that we know can put people at greater risk for experiencing a mental health disorder," Michling says. "That prevention piece, I think, is what's really lost."

A freelance writer and editor, Estelle Slootmaker is happiest writing about social justice, wellness, and the arts. She is development news editor for Rapid Growth Media and chairs The Tree Amigos, City of Wyoming Tree Commission. Her finest accomplishment is her five amazing adult children. You can contact Estelle at Estelle.Slootmaker@gmail.com or www.constellations.biz.

Timothy Michling photos by Steve Koss. Kevin Fischer photo by Doug Coombe. Michelle Schulte photo courtesy of Michelle Schulte.