Shortage or Maldistribution?

To The Editor: In their December 2011 brief report on the national distribution of psychiatric mental health-advanced practice registered nurses (PMH-APRNs), Ghosh and colleagues (1) articulate several questionable conclusions. The authors present a map of the United States that visually demonstrates an asymmetric national distribution of PMH-APRNs, with clustering in urban coastal counties and sparse representation in rural inland counties. The authors recommend increasing the number of PMH-APRNs to correct what they conclude is a “shortage.”

Although the authors' data demonstrate a scarcity in rural areas compared with urban areas, their conclusion that this scarcity of PMH-APRNs equals a shortage is unsupported. On the basis of their data, an equally plausible (although empirically unlikely) conclusion is that affluent urban regions are oversupplied with PMH-APRNs.

The authors' proposal to increase the supply of PMH-APRNs would likely exacerbate their maldistribution and do little to improve access to mental health services in rural areas. In medically underserved areas where recruitment and retention of mental health practitioners is a challenge, provision of training to existing primary care practitioners, consultation via telemedicine, and introduction of incentives for mental health specialists of all backgrounds would be far more effective.