in Psychiatry and Addictions

For the past two decades alcohol and drug abuse and dependency have continued to be the most prevalent psychiatric disorders diagnosed in the general population, and perhaps the most significant public health issue in the United States today.

The Epidemiologic Catchment Area (ECA) study, a survey of mental health and substance related disorders in nearly 20,000 adult Americans, found a 13.5% lifetime prevalence of alcohol abuse and dependence, and 7% lifetime prevalence of drug dependence. In the general population of patients with psychiatric diagnoses, prevalence rates of co-morbidity of alcohol abuse and drug abuse disorders range between 30% and 75%. An estimated 30%-40% of inpatient hospitalizations may be linked to substance abuse and addiction; 25%-50% of emergency room visits in urban centers are substance abuse or addiction related.

Despite the fact that substance use disorders are such a significant problem, there is a great shortage of addiction specialists in psychiatry. The field of psychiatry in general has had difficulty recruiting American medical school graduates. Many programs have depended on international medical graduates (IMGs) to fill a portion of their slots. According to the National Residency Matching Program (NRMP), since 1991 the number of American medical school graduates applying for psychiatry residency programs has declined by 30%. During this period, approximately 45-50% of available psychiatry training positions have been filled by IMGs. Although the number of American medical graduates entering psychiatry residency programs has fluctuated slightly in the past, the trend among students in recent years has been to favor family practice and pediatrics. This reliance on IMGs could leave the profession quite vulnerable if restrictions are placed on IMGs entering US residency programs.

IMGs in the US are not a new phenomenon. Since the passing of the US Information and Education Exchange Act in the early 1960’s, there has been an increase in the pace at which IMGs have come to the US, and in the diversity of countries from which they hail. The IMGs came in large number in the 1960s to fill a shortage of medical manpower. While the shortage was experienced by all specialties, psychiatry was one of the specialties affected to the greatest degree. Historically, IMGs have made important academic contributions to the development of psychiatry.

Shortages of medical manpower usually affect the sickest and the poorest segments of the population. The influx of IMGs into the US healthcare system has enabled it to meet more of the needs of underserved populations. The American Medical Association’s 1993 survey of graduate medical education found that IMGs are three times as likely as their counterparts to practice in poorer and underserved areas of the country. While some see IMGs as a threat because they may take jobs from US born citizens, surveys and studies show that they fill a gap by providing much needed services to populations that American graduates alone are unwilling or unable to serve. Further restrictions on the training and employment of IMGs would have a serious impact on our ability to meet the needs of these already underserved populations.

Persons with substance use disorders comprise one of the subgroups of underserved populations. Sheldon Miller, MD, a director of the American Board of Psychiatry and Neurology and chair of the Residency Review Committee, said recently that one of the many reasons we continue to need addiction psychiatry as a subspecialty is to develop a cadre of teachers and experts to help general psychiatrists do a better job of taking care of these people presenting with very complex needs and clinical challenges. Every year hundreds of deaths occur due to substance use and overdose. This problem affects people across all demographic variables, but treatment opportunities are frequently inaccessible to people living in poor rural areas due to the shortage of qualified professionals.

Even though the number of addiction fellowship programs has increased in recent years, programs have had difficulty filling available slots. American medical graduates have filled a relatively small number of the clinically oriented positions available. The prevalence of substance use disorders in the general population makes it essential that more expertise be developed in addressing this issue in all medical specialties, and particularly in psychiatry. To accomplish this, and to continue to serve this neglected population, medical schools and departments of psychiatry must find ways to spark interest in psychiatry and addiction treatment, and to advocate strongly for advanced fellowship training in addiction psychiatry. It would be very difficult at the present time to meet either of these objectives without the availability of IMGs to assist in this mission. We must recognize that even if we are able to energize the interest of American medical graduates, it will be some time before this new generation would be capable of meeting identified needs. It is critical that we find ways to facilitate the entry of IMGs into psychiatry and addiction treatment if we are to improve our ability to serve this distressed population.