KYLE GREEN The Roanoke Times

Dr. Mark Kilgus (left), chairman of the Department of Psychiatry and Behavioral Medicine at Carilion Clinic, talks with psychiatry resident Dr. Paul DeLapp before rounds Friday at a rehabilitation center in Roanoke.

A long-existing shortage of psychiatrists in Southwest Virginia has recently become more dire, causing some people with mental health conditions to go untreated or undertreated, according to local mental health officials.

Both the Roanoke and New River valleys are below the state rate of psychiatrists per 10,000 people, with the New River Valley facing an extreme shortage.

Only 17 doctors identify themselves as licensed psychiatrists in the New River Valley, according to medical license data maintained by the Virginia Department of Health Professions. That equates to a rate of less than one psychiatrist per 10,000 people.

By comparison, the state average is nearly 2.9 psychiatrists per 10,000 people.

It's a trend that even local insurance giant Anthem Blue Cross and Blue Shield has noticed.

The company, which insures more than half a million people in Southwest Virginia, has seen a "slight declining trend of available psychiatrists in the New River Valley area," spokesman Scott Golden said.

The raw numbers for the Roanoke Valley are better, but they don't necessarily tell the entire story.

There are 100 psychiatrists listed as practicing in Roanoke Valley, according to the data. That's a rate of 2.7 per 10,000 people, but the number includes 23 psychiatrists who practice at the Salem Veterans Affairs Medical Center.

"There is a definite shortage" in Southwest Virginia in general, said Jack Wood, director of Catawba Hospital. "There are just varying degrees."

It's a problem affecting both outpatient and inpatient psychiatric care, said Paula Mitchell, vice president of behavioral health at Lewis-Gale Medical Center. At Lewis-Gale alone, the inpatient provider staff has dwindled to three from 13 a decade ago.

"When there is a shortage anywhere in the system, it affects all of us," Mitchell said. "Even if it is a private practice that closes, all the patients from that doctor are calling and taking up available slots."

A shortage of psychiatrists ultimately affects the number of inpatient beds a facility is able to staff. When outpatient care is limited, the likelihood that someone will go untreated increases and their conditions could worsen, said Dr. Rizwan Ali, past president of the Southwest Virginia Psychiatric Society and an officer of the Psychiatric Society of Virginia. That means more need for inpatient care, he said.

A closer look at the New River Valley psychiatrists shows that not all 17 spend 100 percent of their time practicing in the area, as two divide their time between Charlottesville and Blacksburg.

Shortages impact entire region, system of care

The lack of psychiatrists in New River Valley and other parts of Southwest Virginia has put an increased strain on the already limited resources in the Roanoke Valley.

Anthem's Golden said that while the valley has experienced a decline in the number of psychiatrists,, the entire region meets standards for access and availability of behavior health care. There are about 1.5 psychiatrists available for every 1,000 patients in Anthem's behavioral health network, but that network extends beyond the Roanoke and New River valleys.

"It is safe to say that Anthem members would have to travel to Roanoke from the New River Valley if there wasn't any psychiatry availability in the Blacksburg area," Golden said in an e-mail.

Mental health providers, patients and advocates say there is anecdotal evidence that some patients wait as long as six months for an initial appointment. Others point to the retirement of several psychiatrists as a factor in the shortage.

For years, there has been a shortage of mental health professionals nationwide. Federal data released in June indicates that 76 million people live in areas specifically designated as having a shortage of mental health providers.

The U.S. Health Resources and Services Administration estimates that it would take more than 5,000 new practitioners to meet the mental health needs of Americans. That fact only illustrates another problem: recruiting doctors to the specialty.

Recruiting new psychiatrists to the region is hampered by staunch competition nationally for the dwindling number of students interested in the profession. Wood said he has had trouble recruiting for open positions at Catawba, and others have echoed the difficulties of bringing psychiatrists to various sectors throughout Southwest Virginia.

Since 2005, the number of U.S. medical students taking residency positions in psychiatry has declined nearly 9 percent, according to the National Resident Matching Program. At the same time psychiatry programs have seen interest dwindle, the sizes of medical school graduating classes have grown.

Experts say the decline in interest exists in part because doctors going into other specialities earn higher incomes than psychiatrists.

"The private sector is struggling a lot in Virginia," Ali said of the lack of parity in reimbursements. "Mental health is as important as physical health, and there shouldn't be a bias against someone who has depression as compared to someone who has a heart attack."

Still, in some sectors, such as at the Salem Veterans Affairs Medical Center, there aren't any openings for psychiatrists.

"We currently do not have any vacancies in our psychiatry program, but as the demand has risen for mental health services in our community, we are beginning to feel some of this impact as well," Ann Benois, spokeswoman for the Salem VA Medical Center, wrote in an e-mail. "We have added two psychiatrists to our staff in order to expand mental health services. "

Addressing the shortage through primary care

Dr. Mark Kilgus said the shortage has him looking for solutions, including training primary care physicians on how to treat mental illness.

Kilgus, who is the chairman of the department of psychiatry and behavioral medicine at Carilion Clinic, said the shortage has caused more patients than ever before to be treated in primary care settings for mental illnesses.

"It's probably by default," Kilgus said. "Call any primary care office and ask, 'Do we have enough psychiatrists?' And their answer is, 'Absolutely not.' "

Bob Baldacci said he eventually turned to his primary care doctor when his psychiatrist decided to retire.

Baldacci, 50, of Roanoke said he was diagnosed with bipolar disorder 30 years ago.

The retiring psychiatrist gave Baldacci a list of other psychiatrists in town, but that didn't guarantee that those other psychiatrists had room for new patients.

"I tried calling other places. I figured since I had this list, I could get in, that I would just begin care with them," he said. "But I couldn't."

So, Baldacci asked his primary care doctor to write him the prescriptions.

"I had asked my doctor before, but he didn't feel comfortable prescribing this class of drugs," he said. "But he was able to get me in with a physician assistant."

The physician assistant works with a psychiatrist and will help to keep Baldacci on his medications.

"They were really cool at least to find me this," he said.

Training psychiatrists to help with recruiting

Through his position at Carilion, Kilgus is also trying to address the shortage by building up the psychiatry residency program.

"Research shows us that they [psychiatrist residents] tend to stay in the area they train," Kilgus said. "So this is really good for the Roanoke Valley."

Carilion's four-year residency program has 32 general psychiatrists. In July, two fellowships were added in child psychiatry. Carilion also has one geriatric fellow.

Both geriatric and child specialists are in particular demand , Kilgus said.

Dr. Paul DeLapp is one of the residents completing his final year at Carilion. In June, DeLapp said he wants to set up a private practice in Roanoke.

The Salem VA Medical Center has seen the benefits of having a residency program, Benois said.

The original program began in 1986 as a joint effort with the University of Virginia, and the program has expanded and now is affiliated with Carilion and Catawba. Part of DeLapp's residency program at Carilion has been at the VA Medical Center.

But with student loans that amount to more than his home mortgage, DeLapp said he has a tough financial reality to face once he completes his training and sets out to open a practice.

"Now all of a sudden I have to turn into a businessman," he said.

Another Carilion psychiatrist resident said he's taking a different path by taking advantage of the nationwide -- and global -- shortage to work and live in several different areas.

"A lot of jobs are being created," said Dr. Abhishek Mehra, adding that he is more interested in working in the public sector then opening a private practice. Mehra, like DeLapp, has spent some of his residency at the VA Medical Center.

Mehra said he will likely work for a short-term placement agency so he can travel and treat patients in a variety of places, everywhere from California to Australia.

Still, he added, he isn't going to sell his Roanoke home, just in case he and his wife decide to return.

Data Delivery Editor Matt Chittum contributed to this report.