Contents

• Introduction
• Mental Health Workforce Definition: No Consensus
• Mental Health Workforce Overview
• Licensure Requirements
• Degree
• Supervised Practice
• Exam
• Scope of Practice
• Mental Health Workforce Size
• Mental Health Workforce Annual Wages
• Concluding Comments

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 "core mental health professionals"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 theirtheir 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 core 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 core 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.

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The Mental Health Workforce: A Primer

Introduction

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).¹ Policymakers have demonstrated interest in the federal government's broad role in mental health care. They have done so primarily by holding hearings² and introducing legislation³ 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.

Mental Health Workforce Definition: No Consensus

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 InstituteNational Academy of Medicine (IOMNAM)—a private, nonprofit organization that aims to provide evidence-based health policy advice to decision makersdecisionmakers, often through congressionally mandated studies—has conceptualized the mental health workforce broadly, including primary care physicians, nurses, physician assistants, peer support specialists, and family caregivers, among otherspsychologists, nurses, mental health and substance abuse counselors, care managers and coordinators, and social workers.⁴ 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 in recent years 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.⁵ Previously, SAMSHA's definition also included psychosocial rehabilitation, school psychology, and pastoral counseling and excluded substance abuse counseling.⁶

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 populations⁷—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).⁸ 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 identifies "[c]ore mental health professionals [as] psychiatrists, clinical psychologists, clinical social workers, [advanced practice psychiatric nurses],⁹ and marriage and family therapists"has identified mental health providers as licensed psychiatrists, psychiatric nurses,⁹ psychiatric social workers, clinical psychologists, clinical social workers, and family therapists, who meet specified training and licensing criteria (as detailed in Appendix A). Notably, this definition is limited to highly trained mental health professionals.

Mental Health Workforce Overview

In conceptualizing and outlining the mental health workforce, this report relies on the HRSA definition of "core mental health professionals,"providers, including clinical social workers, clinical psychologists, marriage and family therapists, psychiatrists, and advanced practice psychiatric nurses.¹⁰ For each of the five core 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

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.¹¹

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,¹² 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).¹³

Degree

The degree noted in Table 1 indicates the minimum level of education generally required to be licensed for independent practice.¹⁴ For the core mental health professionals outlined in this report, licensure for independent practice requires the completion of graduate education.¹⁵ 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).

Supervised Practice

For most provider types discussed in this report, licensure for independent practice requires a period of post-graduatepostgraduate 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.

Exam

State licensing boards generally require a passing score on an exam offered by a national body (e.g., the American Board of Psychiatry and NeurologyAssociation 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.

Scope of Practice

The scope of practice for each provider type is established at the state level by state statute, regulation, or guidance. Table 1 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).

Mental Health Workforce Size

Access to mental health care depends in part on the overall number of practicing mental health providers and the number of specific types of providers.¹⁶ As of January 2015, HRSA had designated 4,071 Mental Health Professional Shortage Areas (MHPSAs), including one or more in each state, the District of Columbia, and each of the territories.¹⁷ Although HRSA designates MHPSAs, it does not collect parallel data on the size of the mental health workforce nationally.¹⁸ Figure 1 and Table 2 both present workforce size estimates for each core mental health provider type from

• The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? by the IOM¹⁹ (supplemented with more recent data from the Bureau Labor Statistics,²⁰ one of the sources the IOM used);
• Behavioral Health, United States, 2012 by SAMHSA;²¹ and
• other sources, including professional associations and licensing boards.

Although the number of mental health providers in each profession varies across the three sources,²² each source yields the same order of provider types from most plentiful to least plentiful, as illustrated in Figure 1. According to each data source, clinical social workers are estimated to be the most plentiful, 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.

Figure 1. Workforce Size Estimates, by Mental Health Provider Type

Sources: CRS analysis of data from Institute of Medicine (IOM), The Mental Health and Substance use Workforce for Older Adults: In Whose Hands? (Washington, DC: National Academies Press, 2012), supplemented with more recent data from U.S. Department of Labor, Bureau of Labor Statistics, Occupational Employment Statistics, May 2013 Occupation Profiles, http://www.bls.gov/oes/current/oes_stru.htm.; Substance Abuse and Mental Health Services Administration (SAMHSA), Behavioral Health, United States, 2012, Rockville, MD, 2013; and other sources (i.e., professional associations and licensing boards).

Variation in the numbers from different sources reflects some of the difficulty in determining the size of the workforce—and therefore also in determining the adequacy of the workforce to provide access to mental health care. Along with workforce size estimates for each provider type, Table 2 presents the original data sources (e.g., the IOM report relies on data from the Bureau of Labor Statistics and the National Sample Survey of Registered Nurses for APPNs). Limitations of each original data source may lead to overstating or understating the number of providers (e.g., the Bureau of Labor Statistics data excludes self-employed workers). Major limitations are noted in Table 2.

Even looking at the numbers in relative terms, the limitations of the original sources complicate comparisons across professions. For example, the Bureau of Labor Statistics figures include school psychologists and exclude school social workers, limiting their comparability.

Mental Health Workforce Annual Wages

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 Bureau of Labor Statistics (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.²³ Information from BLS is likely to either over- or under-state Scope of Practice 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). Table 2. Scope of Practice, by Mental Health Provider Type Provider Type^a

Can Diagnose Mental Disorders

Can Provide Psychosocial Treatment for Individuals, Families, and Groups

Can Administer and Interpret Psychological Tests

Can Diagnose and Treat Physical Conditions

Can Prescribe Medication

Clinical Social Worker

Yes

Yes

No

No

No

Clinical Psychologist

Yes

Yes

Yes

No

No^b

Marriage and Family Therapist (MFT)

Yes

Yes

No

No

No

Psychiatrist

Yes

Yes

No

Yes

Yes

Advanced Practice Psychiatric Nurse (APPN)^c

Yes

Yes

No

Yes^d

Yes

Source: U.S. Department of Labor, Bureau of Labor Statistics; U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA); and various professional associations. For more information on the professional organizations for each of the five mental health professions, see Appendix A.

Notes: The table focuses on the 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.

a. The provider type may not correspond to the name of the license (which may vary by state for some provider types). The provider types correspond to HRSA's mental health providers (with the exception of advanced practice psychiatric nurses, which HRSA refers to as "psychiatric nurses"). b. In New Mexico, Louisiana, Illinois, Iowa, Idaho, Guam, the U.S. Department of Defense (DOD) system, the Indian Health Service, and the U.S. Public Health Service, licensed psychologists who obtain additional training can apply to have prescription writing privileges as part of their scope of practice. See Robert E. McGrath, "Prescriptive Authority for Psychologists," Annual Review of Clinical Psychology, vol. 6 (April 27, 2010), pp. 21-47; and American Psychological Association, "Idaho Becomes Fifth State to Allow Psychologists to Prescribe Medications," press release, April 5, 2017, https://www.apa.org/news/press/releases/2017/04/idaho-psychologists-medications.aspx. c. This includes mental health/psychiatric nurse practitioners and clinical nurse specialists. This report uses the term "advanced practice psychiatric nurse," which is more common than the term "psychiatric nurses" used by HRSA. d. Some states may require that advanced practice psychiatric nurses be supervised by physicians. Mental Health Workforce Size

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.¹⁶ 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).

Data Used to Designate MHPSAs

When designating MHPSAs, HRSA attempts to capture the deficit in a particular geographic area of practicing mental health clinicians. As of March 2018, HRSA had designated 5,042 MHPSAs, including one or more in each state, the District of Columbia, and each of the territories. HRSA estimates the population of designated MHPSAs to be 95,399,011 in 2018.¹⁷ To be designated a MHPSA, a state, through its Primary Care Office, applies to HRSA, with the data necessary to demonstrate that a particular area meets the designation criteria. States use a variety of sources when providing these data including professional association data, state licensing data, and state specific survey data. HRSA then reviews these data and makes a final determination about the designation.

Source: Health Resources and Services Administration, Data Warehouse, Health Professional Shortage Areas (HPSA) and Medically Underserved Areas / Populations (MUA/P)," http://datawarehouse.hrsa.gov/topics/shortageAreas.aspx#chart.

HRSA's Area Health Resource Files (AHRF) compiles health-related data from various sources.¹⁸ 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.¹⁹ 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.²⁰ 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.²¹ 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.²² 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.

Clinical Social Workers

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.²³ 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 2016.²⁴ 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.

Clinical Psychologists

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)²⁵ 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 2015.²⁶ 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).²⁷ 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.²⁸ The OOH estimates 147,500 "clinical, counseling, and school psychologists" in 2016.²⁹

Marriage and Family Therapists

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.³⁰ The workforce size of MFTs increased from 2016 to 2017 by 13.8%.³¹ The OOH estimates 41,500 MFTs in 2016, including those who are self-employed.³² Recent estimates of the number of MFTs are not publicly available from the CPS, membership organizations, or licensing boards.

Psychiatrists

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.³³ 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.³⁴ The American Medical Association (AMA), a physician membership organization, gathers physician workforce information in the Physician Masterfile.³⁵ Using the Physician Masterfile, the AMA estimated 37,938 self-designated psychiatrists in 2013 (the most recent data publicly available).³⁶ The CPS does not have publicly available estimates of the psychiatrist workforce size.

Advanced Practice Psychiatric Nurses (APPN)

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.³⁷ The OES, OOH, and CPS do not distinguish between APPNs and other advanced practice nurses.

Mental Health Workforce Annual Wages 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.³⁸ 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),³⁹ 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.

Concluding Comments

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.²⁴40 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.²⁵41 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.²⁶42 As such, the cost of employing different provider types—as well as their scopes of practice—may be a consideration not only in determining staffing priorities, but also in attempts to recruit and retain mental health providers (e.g., by offering competitive compensation).

Appendix A. Mental Health Professional Shortage Areas (MHPSA) Definition

This appendix excerpts the specific criteria that the Health Resources and Services Administration (HRSA) uses to designate mental health professional shortage areas (MHPSAs). MHPSAs can be geographic areas, population groups, or facilities. This designation is used to determine eligibility for federal programs such as Medicare bonus payments and health professions recruitment programs. HRSA bases the MHPSA designation on the availability (relative to population size) of "core mental health professionals," which include "psychiatrists, clinical psychologists, clinical social workers, psychiatric nurse specialists, and marriage and family therapists." The criteria for designating a MHPSA are as follows:²⁷

1. Geographic Areas must:

• Be a rational area for the delivery of mental health services
• Meet one of the following conditions:
• A population-to-core-mental-health-professional ratio greater than or equal to 6,000:1 and a population-to-psychiatrist ratio greater than or equal to 20,000:1 or
• A population-to-core professional ratio greater than or equal to 9,000:1 or
• A population-to-psychiatrist ratio greater than or equal to 30,000:1
• Have unusually high needs for mental health services, and
• A population-to-core-mental-health-professional ratio greater than or equal to 4,500:1 and a population-to-psychiatrist ratio greater than or equal to 15,000:1, or
• A population-to-core-professional ratio greater than or equal to 6,000:1, or
• A population-to-psychiatrist ratio greater than or equal to 20,000:1
• Mental health professionals in contiguous areas are overutilized, excessively distant or inaccessible to residents of the area under consideration.

2. Population Groups must:

• Face access barriers that prevent the population group from use of the area's mental health providers
• Meet one of the following criteria:
• Have a ratio of the number of persons in the population group to the number of FTE core mental health professionals serving the population group greater than or equal to 4,500:1 and the ratio of the number of persons in the population group to the number of FTE psychiatrists serving the population group greater than or equal to 15,000:1; or
• Have a ratio of the number of persons in the population group to the number of FTE core mental health professionals serving the population group greater than or equal to 6,000:1; or
• Have a ratio of the number of persons in the population group to the number of FTE psychiatrists serving the population group are greater than or equal to 20,000:1

3. Facilities must:

• Be maximum or medium security facilities
• Be either Federal and/or State correctional institutions, State/County mental hospitals or public and/or non-profit mental health facilities
• Federal or State Correctional facilities must:
• Have at least 250 inmates and
• Have a ratio of the number of internees per year to the number of FTE [full-time equivalent] psychiatrists serving the institution of at least 2,000:1
• State and county mental health hospitals must:
• Have an average daily inpatient amount of at least 100; and
• The number of workload units per FTE psychiatrists available at the hospital exceeds 300, where workload units are calculated using the following formula: Total workload units = average daily inpatient census + 2 x (number of inpatient admissions per year) + 0.5 x (number of admissions to day care and outpatient services per year).
• Community mental health centers and other public and non-profit facilities must:
• Be providing (or responsible for providing) mental health services to an area or population group designated as having a shortage of mental health professionals and
• Have insufficient capacity to meet the psychiatric needs of the area or population group

B. Methodology.²⁸

In determining whether an area meets the criteria... the following methodology will be used:

1. Rational Areas for the Delivery of Mental Health Services.

(a) The following areas will be considered rational areas for the delivery of mental health services:

(i) An established mental health catchment area, as designated in the State Mental Health Plan under the general criteria set forth in section 238 of the Community Mental Health Centers Act.

(ii) A portion of an established mental health catchment area whose population, because of topography, market and/or transportation patterns or other factors, has limited access to mental health resources in the rest of the catchment area, as measured generally by a travel time of greater than 40 minutes to these resources.

(iii) A county or metropolitan area which contains more than one mental health catchment area, where data are unavailable by individual catchment area.

(b) The following distances will be used as guidelines in determining distances corresponding to 40 minutes travel time:

(i) Under normal conditions with primary roads available: 25 miles.

(ii) In mountainous terrain or in areas with only secondary roads available: 20 miles.

(iii) In flat terrain or in areas connected by interstate highways: 30 miles.

Within inner portions of metropolitan areas, information on the public transportation system will be used to determine the distance corresponding to 40 minutes travel time.

2. Population Count.

The population count used will be the total permanent resident civilian population of the area, excluding inmates of institutions.

3. Counting of mental health professionals.

(a) All non-Federal core mental health professionals (as defined below) providing mental health patient care (direct or other, including consultation and supervision) in ambulatory or other short-term care settings to residents of the area will be counted. Data on each type of core professional should be presented separately, in terms of the number of full-time-equivalent (FTE) practitioners of each type represented.

(b) Definitions:

(i) Core mental health professionals or core professionals includes those psychiatrists, clinical psychologists, clinical social workers, psychiatric nurse specialists, and marriage and family therapists who meet the definitions below.

(ii) Psychiatrist means a doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who

(A) Is certified as a psychiatrist or child psychiatrist by the American Medical Specialties Board of Psychiatry and Neurology or by the American Osteopathic Board of Neurology and Psychiatry, or, if not certified, is "board-eligible" (i.e., has successfully completed an accredited program of graduate medical or osteopathic education in psychiatry or child psychiatry); and

(B) Practices patient care psychiatry or child psychiatry, and is licensed to do so, if required by the State of practice.

(iii) Clinical psychologist means an individual (normally with a doctorate in psychology) who is practicing as a clinical or counseling psychologist and is licensed or certified to do so by the State of practice; or, if licensure or certification is not required in the State of practice, an individual with a doctorate in psychology and two years of supervised clinical or counseling experience. (School psychologists are not included.)

Clinical social worker means an individual who—

(A) Is certified as a clinical social worker by the American Board of Examiners in Clinical Social Work, or is listed on the National Association of Social Workers' Clinical Register, or has a master's degree in social work and two years of supervised clinical experience; and

(B) Is licensed to practice as a social worker, if required by the State of practice.

(v) Psychiatric nurse specialist means a registered nurse (R.N.) who—

(A) Is certified by the American Nurses Association as a psychiatric and mental health clinical nurse specialist, or has a master's degree in nursing with a specialization in psychiatric/mental health and two years of supervised clinical experience; and

(B) Is licensed to practice as a psychiatric or mental health nurse specialist, if required by the State of practice.

(vi) Marriage and family therapist means an individual (normally with a master's or doctoral degree in marital and family therapy and at least two years of supervised clinical experience) who is practicing as a marital and family therapist and is licensed or certified to do so by the State of practice; or, if licensure or certification is not required by the State of practice, is eligible for clinical membership in the American Association for Marriage and Family Therapy.

Appendix B. 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://www2www.aaap.org

/

American Academy of Child & Adolescent Psychiatry (AACAP): http://www.aacap.org

/

American Academy of Clinical Psychiatrists (AACP): httpshttp://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.psych.orgpsychiatry.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): httpshttp://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

Acknowledgments

Jimmylee Gutierrez conducted background research for this report during an internship with CRS. Adam Salazar, Research Assistant, provided valuable assistance in updating this/

Author Contact Information

Acknowledgments

Brianne Ramos provided valuable assistance in updating this report during an internship with CRS. The authors would also like to acknowledge [author name scrubbed], Jimmylee Gutierrez, and Adam Salazar for their contributions to previous versions of the report.

Footnotes

For a description of health workforce programs, see CRS Report R41278, Public Health, Workforce, Quality, and Related Provisions in ACA: Summary and Timeline and U.S. Government Accountability Office (GAO), Health Care Workforce: Federally Funded Training Programs in Fiscal Year 2012, 13-709R, August 15, 2013, http://www.gao.gov/products/GAO-13-709R.

1.	For example, federal agencies such as the Veterans Health Administration (within the Department of Veterans Affairs) provide mental health care directly; federal programs such as Medicare pay for mental health care; and federal agencies such as the Substance Abuse and Mental Health Services Administration (within the Department of Health and Human Services) support mental health care through grant funding, dissemination of best practices, technical assistance, and other means.
2.	See, for example, U.S. Congress, House Committee on Energy and CommerceVeterans' Affairs, Subcommittee on Health, Healthy Hiring: Enabling VA to Recruit and Retain Quality Providers, 115th Cong., 1st sess., March 22, 2017; U.S. Congress, Senate Committee on Appropriations, Subcommittee on Departments of Labor, Health and Human Services, and Education, and Related Agencies, "Mental Health Care: Examining Treatments and Services," 115th Cong., 1st sess., February 15, 2017, Subcommittee on Oversight and Investigations, Federal Efforts on Mental Health: Why Greater HHS Leadership is Needed, 114th Cong., 1st sess., February 11, 2015; U.S. Congress, House Committee on Energy and Commerce, Subcommittee on Oversight and Investigations, Where Have All the Patients Gone? Examining the Psychiatric Bed Shortage, 113th Cong., 2nd sess., March 26, 2014; and U.S. Congress, Senate Committee on Health, Education, Labor, and Pensions, Examining Mental Health: Treatment Options and Trends, 113th Cong., 2nd sess., February 25, 2014.
3.	For example, in the 113115th Congress, bills were introduced intended to improve mental health care overall (e.g., H.R. 12631253, H.R. 3717, S. 264, and S. 6894778, H.R. 2345), and for specific populations such as veterans (e.g., H.R. 1725 and H.R. 2540), school children (e.g., H.R. 320 and H.R. 628Asian American, Native Hawaiian, and Pacific Islanders (e.g., H.R. 2677), youth in foster care, (e.g., S. 439), veterans (e.g., H.R. 897, S. 1881), law enforcement officers (e.g., H.R. 2228, S. 867), and Medicare beneficiaries (e.g., H.R. 794 and S. 562),1290, H.R. 1173, S. 448) among others.
4.	IOM (Institute of Medicine). 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? Washington, DC: The National Academies Press. Hereinafter, IOM Workforce Report. The IOMJames Knickman et al., Improving Access to Effective Care for People Who Have Mental Health and Substance Use Disorders: A Vital Direction for Health and Health Care, National Academy of Medicine, September 9, 2016, https://nam.edu/wp-content/uploads/2016/09/Improving-Access-to-Effective-Care-for-People-Who-Have-Mental-Health-and-Sustance-Use-Disorders.pdf. The NAM definition also includes all fields in the SAMHSA definitions.
5.	SAMHSA. (2013). Behavioral Health, United States, 2012. HHS Publication No. (SMA) 13-4797. Rockville, MD: SAMHSA.
6.	SAMHSA. (2006) Mental Health, United States, 2004. HHS Publication No. (SMA) 06-4195. Rockville, MD: SAMHSA. The IOMNAM definition includes all fields in the SAMHSA definitions.
7.	HRSA, About HRSA, http://www.hrsa.gov/about/.
8.	Health professional shortage areas (HPSAs) are defined in 42 U.S.C. §254e. HRSA developed operational definitions of HPSAs and of MHPSAs specifically, available at http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/designationcriteria.html and http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/mentalhealthhpsaoverview.html. HRSA designates MHPSAs based on the ratio of mental health providers to population. As of January 2015March 2018, HRSA had designated 4,0715,042 MHPSAs. See U.S. Department of Health and Human Services, Health Resources and Services Administration, "Health Professional Shortage Areas (HPSA) and Medically Underserved Areas/Populations (MUA/P)," http://datawarehouse.hrsa.gov/topics/shortageAreas.aspx#chart. For a larger discussion of HPSAs, of which MHPSAs are a specific type, see CRS Report R42029, Physician Supply and the Affordable Care Act.
9.	This report uses the term "advanced practice psychiatric nurse," which is more common than the term "psychiatric nurse specialistsnurses" used in HRSA's MHPSA designation criteriaHealth Center Program Terms and Definitions. See U.S. Department of Health and Human Services, Health Resources and Services Administration, "Mental Health HPSA Designation Overview," http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/mentalhealthhpsaoverview.html. Health Center Program Terms and Definitions," https://www.hrsa.gov/sites/default/files/grants/apply/assistance/Buckets/definitions.pdf.
10.	The HRSA definition is used because of its relevance to federal workforce programs and other incentive programs designed to improve access to care. See U.S. Department of Health and Human Services Administration, Health Resources and Services Administration, "Types of Designations," https://bhw.hrsa.gov/shortage-designation/types.
11.	See, for example, "FSMB Mission and GoalsAbout FSMB," Federation of State Medical Boards at http://www.fsmb.org/mission.htmlabout-fsmb/fsmb-overview.
12.	In order for a health professional to "count" for MHPSA designation purposes, the health professional must be licensed to practice independently.
13.	As licensure requirements change over time, previously licensed providers may not be subject to new requirements.
14.	Some disciplines offer degrees with the same title in both clinical and non-clinical tracks—for example, a Doctor of Philosophy (PhD) in clinical psychology and a PhD in experimental psychology or a Masters of Social Work (MSW) in clinical social work and an MSW social work administration—where graduates of the non-clinical track are not qualified for clinical licensure.
15.	Licensure generally requires a degree from a school or program that has been accredited; however, a discussion of accreditation of educational institutions and programs is beyond the scope of this report.
16.	One of the primary challenges in assessing the overall size of the mental health workforce is that there is no uniform definition; see "Mental Health Workforce Definition: No Consensus." Using the HRSA definition of "core mental health professionals,"providers, a relatively narrow definition, yields a smaller estimate than would be found using a somewhat broader definition such as the one used by SAMSHA or a much broader definition such as the one used by the IOMNAM.
17.	Health Resources and Services Administration, Data Warehouse, Health Professional Shortage Areas (HPSA) and Medically Underserved Areas / Populations (MUA/P)," http://datawarehouse.hrsa.gov/topics/shortageAreas.aspx#chart.
18.	HRSA uses a variety of data sources when designating MHPSAs. Individual states apply to HRSA for MHPSA designations. When doing so states must provide data on the ratio of health practitioners to population. States use a variety of sources when providing these data including professional association data, state licensing data, and state specific survey data. Source: E-mail from HHS Office of the Assistant Secretary for Legislation, August 1, 2013. In November 2013, HRSA released a chartbook that included counts of certain behavioral health professions (e.g., psychologists and counselors); these data are not used in this CRS report because they do not include all professions included in the MHPSA definition nor do they restrict counts to clinical practitioners. For more information, see U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis, The U.S. Health Workforce Chartbook, Part IV: Behavioral and Allied Health, Rockville, MD, November 2013.
19.	Institute of Medicine. (2012). The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? Washington, DC: The National Academies Press. IOM is a private, nonprofit institution established in 1970 under the congressional charter of the National Academy of Sciences to provide health policy advice. See National Academies, Institute of Medicine, About the IOM, http://www.iom.edu/About-IOM.aspx. For information about the health professions included in the IOM's definition of the mental health workforce, see "Mental Health Workforce Definition." The IOM used data from the Bureau of Labor Statistics for 2011 in the IOM book. This CRS report uses 2013 data from the same source. IOM also used data for Advanced Practice Psychiatric Nurses (APPN) from the National Sample Survey of Registered Nurses. This survey, commissioned by HRSA, was last conducted in 2008.
20.	U.S. Department of Labor, Bureau of Labor Statistics, Occupational Employment Statistics, May 2013 Occupation Profiles, http://www.bls.gov/oes/current/oes_stru.htm.
21.	Substance Abuse and Mental Health Services Administration (SAMHSA). (2013). Behavioral Health, United States, 2012. HHS Publication No. (SMA) 13-4797. Rockville, MD: SAMHSA. SAMHSA is a public health agency established within HHS by Congress in 1992 to advance mental health in the United States. See SAMHSA, About Us, http://beta.samhsa.gov/about-us. For information about the health professions included in the SAMSHA's definition of the mental health workforce, see "Mental Health Workforce Definition: No Consensus."
22.	The numbers obtained vary in part because these data sources rely on different methodologies including surveys, state licensure data, and membership in professional associations.
23.	For example, the BLS Handbook of Methods, Chapter 3: Occupational Employment Statistics discusses the uses of the OES data that include federal programs, state workforce agencies, and the Department of Labor Foreign Labor Certification Program, see http://www.bls.gov/opub/hom/homch3.htm#uses.
24.	CRS Report R42029, Physician Supply and the Affordable Care Act, discusses the interplay between the demand for health services and the supply of a specific type of providers: physicians. Some of the discussion and some of the policy levers used to affect physician supply could also be used to affect the mental health workforce. For a description of health workforce programs, see CRS Report R41278, Public Health, Workforce, Quality, and Related Provisions in ACA: Summary and Timeline; CRS Report R42029, Physician Supply and the Affordable Care Act,U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, Designated Professional Shortage Areas Statistics, January 2018.
18.	U.S. Department of Health and Human Services, Health Resources and Services Administration, "Area Health Resources Files, State and National Level Data," https://datawarehouse.hrsa.gov/DataDownload/AHRF/AHRF_SN_User_Tech_2016-2017.zip.
19.	The 2009 data were obtained by the National Center for the Analysis of Healthcare Data (NCAHD) from state licensing boards. Established in 2007, NCAHD is a private research center that collects and analyzes healthcare workforce data.
20.	U.S. Department of Labor (DOL), Bureau of Labor Statistics (BLS), Occupational Employment Statistics: Frequently Asked Questions, updated March 31, 2017, https://www.bls.gov/oes/oes_ques.htm.
21.	U.S. DOL, BLS, "Current Population Survey, Employed persons by detailed occupation, sex, race, and Hispanic or Latino ethnicity," https://www.bls.gov/cps/cps_over.htm.
22.	U.S. DOL, BLS, "Occupational Outlook Handbook," https://www.bls.gov/ooh/home.htm.
23.	U.S. DOL, BLS, "Occupational Employment Statistics, Occupational Employment and Wages, May 2017, Mental Health and Substance Abuse Social Workers," https://www.bls.gov/oes/current/oes211023.htm.
24.	U.S. DOL, BLS, "Occupational Outlook Handbook, Social Workers," https://www.bls.gov/ooh/community-and-social-service/social-workers.htm#tab-3.
25.	A membership organization for psychologists.
26.	Auntré Hamp et al., 2015 APA Survey of Psychology Health Service Providers, American Psychological Association, September 2016, http://www.apa.org/workforce/publications/15-health-service-providers/index.aspx.
27.	U.S. DOL, BLS, "Occupational Employment Statistics, Occupational Employment and Wages, May 2017, Clinical, Counseling, and School Psychologists," https://www.bls.gov/oes/current/oes193031.htm.
28.	U.S. DOL, BLS, "Current Population Survey, Labor Force Statistics, Psychologists," https://www.bls.gov/cps/cpsaat11.htm.
29.	U.S. DOL, BLS, "Occupational Outlook Handbook, Psychologists, Work Environment," https://www.bls.gov/ooh/life-physical-and-social-science/psychologists.htm#tab-3.
30.	U.S. DOL, BLS, Occupational Employment Statistics, "Occupational Employment and Wages, May 2017, Marriage and Family Therapists," https://www.bls.gov/oes/current/oes211013.htm.
31.	The MFT workforce is projected to grow 23% from 2016 to 2026, much faster than the average for all occupations. See U.S. DOL, BLS, "Occupational Outlook Handbook," https://www.bls.gov/ooh/community-and-social-service/marriage-and-family-therapists.htm.
32.	U.S. DOL, BLS, "Occupational Outlook Handbook, Marriage and Family Therapists" https://www.bls.gov/ooh/community-and-social-service/marriage-and-family-therapists.htm.
33.	U.S. DOL, BLS, "Occupational Employment Statistics, Occupational Employment and Wages, May 2017, Psychiatrists," https://www.bls.gov/oes/current/oes291066.htm.
34.	U.S. DOL, BLS," Occupational Outlook Handbook, Physicians and Surgeons, Work Environment," https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm#tab-3.
35.	Despite being widely used and considered to be the major source of data on the physician population, these data have been criticized by some because, for example, they do not adequately track retired physicians and because they do not count hours worked by physicians. For example, see Diane R. Rittenhouse et al., "No Exit: An Evaluation of Measures of Physician Attrition," Health Services Research, vol. 39, no. 5 (October 2004), pp. 1571-1588, and Chiang-Hua Chang et al., "Primary Care Physician Workforce and Medicare Beneficiaries' Health Outcomes," Journal of the American Medical Association, vol. 305, no. 20 (May 25, 2011), pp. 2096-2105.
36.	American Medical Association, Physician Characteristics and Distribution in the US, 2015, p. 26. The AMA is the largest association of physicians and medical students in the United States. Data is derived from the AMA's Physician Masterfile, which is the most comprehensive source of information for doctors of medicine (MDs) in the United States.
37.	Kathleen R. Delaney, "Psychiatric Mental Health Nursing Advanced Practice Workforce: Capacity to Address Shortages of Mental Health Professionals," Psychiatric Services, vol. 68, no. 9 (September 2017). To calculate the number of APPNs in 2015, the author adds the American Nurses Credentialing Center's numbers of certified psychiatric mental health nurse practitioners and certified psychiatric clinical nurse specialists. Estimates for 2016 were calculated using the same methodology. See American Nurses Credentialing Center, 2016 Certification Data, https://www.nursingworld.org/globalassets/docs/ancc/2016ancccertificationdatawebsite-1.pdf.
38.	For example, the BLS Handbook of Methods, Chapter 3: Occupational Employment Statistics, discusses the uses of the OES data that include federal programs, state workforce agencies, and the Department of Labor Foreign Labor Certification Program, see http://www.bls.gov/opub/hom/homch3.htm#uses.
39.	Providers in private practice may or may not be considered self-employed.
40.
2541.	BLS projects the growth rate between 20122016 and 20202026 to be 117% among all occupations, 2215% among health care practitioners, and higher within some of the mental health professions (e.g., 3123% among marriage and family therapists and 2319% among mental health and substance abuse social workers). Department of Labor, Bureau of Labor Statistics, "Employment Projections, Employment by Occupation," December 19, 2013January 30, 2018, http://www.bls.gov/emp/ep_table_102.htm.
2642.	See, for example, U.S. Congress, House Committee on Veterans' AffairsAppropriations, Subcommittee on Military Construction, Veteran Affairs, and Related Agencies, Public Witness Hearing, committee print, prepared by Heather O'Beirne Kelly, Director for Veterans and Military Health Policy, Subcommittee on Health, Human Resources Challenges with the Veterans Health Administration, committee print, prepared by Randy Phelps, Deputy Executive Director for Professional Practice of the American Psychological Association, 110115th Cong., May 22, 2008March 29th, 2017, http://veterans.house.gov/witness-testimony/randy-phelps-phd; psychologist recruiting information from the Federal Bureau of Prisons at http://www.bop.gov/jobs/hsd/psychology_services.jspl; and social work recruiting information from the Department of Veterans Affairs at http://www.vacareers.va.gov/resources/downloads/MHEI_Brochure.pdf.
27.	See U.S. Department of Health and Human Services, Health Resources and Services Administration, "Mental Health HPSA Designation Overview," http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/mentalhealthhpsaoverview.html.
28.	U.S. Department of Health and Human Services, Health Resources and Services Administration, "Mental Health HPSA Designation Criteria," http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/mentalhealthhpsacriteria.htmldocs.house.gov/meetings/AP/AP18/20170329/105774/HHRG-115-AP18-Wstate-KellyH-20170329.pdf. See also social work recruiting information from the Department of Veterans Affairs at http://www.vacareers.va.gov/resources/downloads/MHEI_Brochure.pdf.