2010 Indiana Mental Health Professionals Re-Licensure Survey Report

Transcription

1 2010 Indiana Mental Health Professionals Re-Licensure Survey Report Produced by: The Indiana Center for Health Workforce Studies Bowen Research Center, Department of Family Medicine Indiana University School of Medicine In collaboration with the: Indiana Area Health Education Centers Program January 2012 Authors: Cynthia K. Lewis, MPH Zachary T. Sheff, BS, BA Amy E. Richard, BS Amy J. Brandt, BS Terrell W. Zollinger, DrPH AHEC

2 2010 Indiana Mental Health Professionals Re-Licensure Survey Report Produced by: The Indiana Center for Health Workforce Studies Bowen Research Center, Department of Family Medicine Indiana University, School of Medicine In Collaboration with: The Indiana Area Health Education Centers Program January 2012 Cynthia K. Lewis, MPH Zachary T. Sheff, BS, BA Amy E. Richard, BS Amy J. Brandt, BS Terrell W. Zollinger, DrPH i

3 Table of Contents Acknowledgements... iv Executive Summary... v Introduction... v Methods... v Results... v Mental Health Professional Re-Licensure Survey... v Clinical Psychologists... vi Psychiatric Physicians... vi Psychiatric Advanced Practice Nurses... vi Location... vii Conclusions... vii Chapter 1: Introduction... 1 Data Analysis... 1 Chapter 2: Responses to the 2010 Indiana Mental Health Professionals (Master s-trained) Re-Licensure Survey... 2 Methods... 2 Inclusion and Exclusion Criteria... 3 Weighting for County Level Data... 4 Survey Response Rate... 4 Demographic Composition... 5 Practice Characteristics... 8 Special Skills or Training Chapter 3: Responses to the 2010 Clinical Psychologist Re-Licensure Survey Methods Inclusion and Exclusion Criteria Weighting for County Level Data Survey Response Rate Demographic Composition Practice Characteristics Special Skills or Training Chapter 4: Responses of 2011 Indiana Physician Survey, Psychiatrists Only ii

4 Methods Inclusion and Exclusion Criteria Weighting for County Level Data Survey Response Rate Demographic Composition Education or Training Practice Characteristics Chapter 5: Responses to the 2011 Indiana Psychiatric Advanced Practice Nurse Electronic Survey Methods Inclusion and Exclusion Criteria Weighting for County Level Data Survey Response Rate Demographic Composition Education or Training Professional Characteristics Chapter 6: Location of Mental Health Professionals by County in Indiana Masters-trained Mental Health Professionals Distribution Psychologists Distribution Psychiatrists Distribution Psychiatric Advanced Practice Nurses Distribution Masters Trained Mental Health Professionals Ratios Psychologists Ratio Psychiatrists Ratio Psychiatric Advanced Practice Nurses Ratio Chapter 7: Conclusions Appendix 1- A: 2010 Indiana Mental Health Professionals Re-Licensure Survey Appendix I-B: 2010 Clinical Psychologists Re-Licensure Survey Appendix 1-C: 2009 Indiana Physician Re-Licensure Survey SPECIALTY LIST Appendix 1D: 2011 Indiana Psychiatric Advanced Practice Nurse On-line Survey iii

5 Acknowledgements We would like to extend our gratitude to all the talented and dedicated individuals who provided valuable and timely assistance to us during the project. Preparing this report required the assistance, cooperation, and effort of many individuals and agency staff. The survey data and additional data elements were provided by the Indiana Professional Licensing Agency through the Indiana State Department of Health. An advisory committee provided direction and insights regarding the data analysis and report generation: Margaret Adamek, PhD, Director of PhD program, Indiana University School of Social Work Jennifer Bruner, Staff Attorney, Indiana State Department of Health Andrew Chambers, MD, Associate Professor of Psychiatry, Fellow in Psychiatric Addictionology, Assistant Medical Director, Indiana Division of Mental Health and Addiction, Indiana University School of Medicine; Director of Laboratory for Translational Neuroscience of Dual Diagnosis & Development, Institute of Psychiatric Research Tasha Coleman, Board Director, Psychology board, Indiana Professional Licensing Agency Emilee Delbridge, MA, LMFT, Visiting Lecturer, Behavioral Science Intern, Department of Family Medicine, Indiana University School of Medicine Josephine Hughes, MSW, LCSW, Executive Director, National Association of Social Workers: Indiana Chapter Ernest Klein, RN, CAE, Executive Director, Indiana State Nurses Association Thomas McGee, Board Director, Behavioral Health and Human Services board, Indiana Professional Licensing Agency John McGrew, PhD, Director, Clinical Psychology program, Professor of Psychology, Indiana University Purdue University-Indianapolis School of Science, Department of Psychology The cooperation and support of the Indiana State Department of Health was instrumental in obtaining the survey data delivery and interpretation. The authors are grateful for the financial support received from the Indiana Area Health Education Centers Program to produce this report. Cynthia K. Lewis, MPH Zachary T. Sheff, BS, BA Amy E. Richard, BS Amy J. Brandt, BS Terrell W. Zollinger, DrPH iv

6 Executive Summary Introduction The 2010 Indiana Mental Health Professionals Re-Licensure Survey, the 2010 Clinical Psychologists Re-Licensure Survey, and the 2011 Physician Re-Licensure Survey were administered by the Indiana Professional Licensing Agency under a contract with the Indiana State Department of Health. The 2011 Psychiatric Advanced Practice Nurse Survey was administered by the Indiana Nursing Association. This report summarizes the responses to these four surveys. The purpose of this report is to provide a comprehensive description of the mental health workforce in Indiana. Methods The survey instruments included items regarding demographic composition, practice characteristics, and special skills or training. This report includes the survey responses from only those mental health professionals, clinical psychologists, psychiatric nurses and psychiatrists who met the inclusion criteria. A total of 4,950 masters-trained mental health professionals were included in the analyses presented in this report, as were 851 clinical psychologists and 52 psychiatric advanced practice nurses. All 459 psychiatrists who met the inclusion criteria and identified one of the following specialties: addiction medicine, psychiatry, addiction psychiatry, child psychiatry, forensic psychiatry, geriatric psychiatry, pain medicine psychiatry, psychoanalysis psychiatry, or psychosomatic medicine psychiatry also were included in this report. Inclusion criteria required the professionals to identify their practice location as a non-federal psychiatric hospital, possess an active or probationary license, identify Indiana as their primary practice location, and answer at least one question on the survey instrument. Results Mental Health Professional Re-Licensure Survey The masters-trained mental health professionals in this chapter include social workers, marriage and family therapists, mental health counselors and other masters-trained mental health professionals One-third of the respondents were younger than 44 years of age and forty percent were at or near retirement age (55 and older). There were more than three times as many female respondents (76.6%) as there were male (23.4%) respondents. A majority of the respondents were white (92.4%) and 98 percent were of non-hispanic origin. The majority of respondents professional time was spent in social work followed by mental health counseling. Mental health professionals specializing in marriage and family therapy made up only 8.6 percent of respondents, and 41.8 percent of these were between the ages of 55 v

7 and 64. The most common specialty areas of respondents were: general mental health, anxiety disorders, and mood disorders. Clinical Psychologists Clinical psychologists were evenly split between males and females (50.1% and 49.9%, respectively). Nearly half of respondents (47.7%) were between the ages of 35 and 54. Gender and age cross-tabulation revealed that 80.2 percent of psychologists under the age of 35 were female and that 63.1 percent of respondents over the age of 54 were male. The majority of respondents were white (93.9%) and non-hispanic (98.1%). Respondents reported that direct patient care took up the majority of their time at work (79.2%), and only 6.4 percent of respondents performed jobs that did not include patient care. Over two-thirds of respondents indicated that they worked 40 or more hours per week (70.2%). Of psychologists working less than 10 hours per week, 58.2 percent were over the age of 55. Psychiatric Physicians Physicians who indicated that they were practicing in one of the following specialties: addiction medicine, psychiatry, addiction psychiatry, child psychiatry, forensic psychiatry, geriatric psychiatry, pain medicine psychiatry, psychoanalysis psychiatry, or psychosomatic medicine psychiatry, were included in this report. There are nearly twice as many males (64.8%) as females (35.2%) and most respondents were white (70.0%) and of non-hispanic origin (96.0%). Almost half of all respondents (48.1%) were between the ages of 35 and 54, and the mean age of respondents was 52.6 years old. The majority of survey respondents completed residency and/or fellowship training in the United States, but in a state other than Indiana. Over half spent 40 or more hours per week performing all psychiatric physician activities. The majority did accept Medicaid patients. Psychiatric Advanced Practice Nurses The majority of psychiatric advanced practice nurses were white (96.2%), female (92.2%), and non-hispanic (98.0%). The most common degree obtained by psychiatric advanced practice nurses was a Master s (75.0%). Psychiatric advanced practice nurses most often worked in public/community health settings (30.8%) and hospitals (26.9%). Approximately one-half (47.1%) of psychiatric advanced practice nurses worked more than 40 hours per week. The primary work activity for 55.8 percent of respondents was psychopharmacological intervention. One-quarter of the respondents worked multiple jobs. Only 3.83 percent of respondents indicated that they were two to three years from retirement while 55.8 percent said that they were more than 10 years from retiring. vi

8 Location Graphic information system (GIS) maps illustrated that, as expected, the counties with the highest populations generally had the most mental health professionals. The maps illustrate estimated number of mental health professionals, social workers, marriage and family therapists, mental health counselors and other mental health professions separately. Conclusions Mental health professionals and psychiatric advanced practice nurses were predominantly white, non-hispanic females. Clinical psychologists were evenly distributed among male and females, but females seem to be entering the field in much greater numbers than males. Psychiatric physicians were predominantly white, non-hispanic males. Most respondents reported that the majority of their time at work was spent providing direct patient care. As expected, the distribution of mental health professionals was higher in areas with higher population. The gender gap that exists in mental health professionals and psychiatric advanced practice nurses should be addressed, as well as the lack of racial and ethnic diversity and need for more bilingual mental health professionals. Individuals considering a career in healthcare should be encouraged to enter the mental health field. vii

9 Chapter 1: Introduction Understanding the personal and professional characteristics of mental health professionals licensed in Indiana is essential for the development and management of programs that effectively recruit and retain mental health professionals where they are most needed in the state. Quality data about mental health professionals in Indiana will help policymakers and other stakeholders make better-informed decisions regarding the mental health professional workforce in our state. The purpose of this report is to provide those data. The findings from this report may be used to identify mental health professional shortage areas and develop more effective recruitment and retention strategies. The Indiana State Department of Health (ISDH) and the Indiana Professional Licensing Agency (IPLA) collaborated in implementing the 2010 Indiana Mental Health Professionals Re-Licensure Survey, the 2010 Clinical Psychologists Re-Licensure Survey, and the 2011 Physician Re-Licensure Survey. The 2011 Psychiatric Advanced Practice Nurse Survey was administered by the Indiana Nursing Association. All mental health professionals who renewed their licenses online, as well as the psychiatric advanced practice nurses were asked to complete a voluntary survey instrument. This report summarizes the responses to these surveys to provide a comprehensive description of the mental health workforce in Indiana. Data Analysis Frequency and cross-tabulation analyses were performed to describe the characteristics of the mental health professionals within Indiana. The data were coded in Microsoft Excel 2007 and analyzed using SAS 9.3 and IBM SPSS Statistics 19. Graphical information system (GIS) maps were developed to illustrate the number of mental health professionals per Indiana county, as well as the number of mental health professionals per 100,000 residents. Rural counties are defined by the United States Department of Agriculture as non-metropolitan counties and are designated by hash marks on the maps. The GIS maps were designed in ArcGIS 9.3. The estimated number of mental health professionals per county was based on the respondents principal practice location. The total number of respondents in each county was adjusted using a weight calculated for each profession, except for psychiatric advanced practice nurses, in order to estimate the total number of mental health professionals available to serve the community in each county. Thus, the counts of the masters-trained mental health professionals, clinical psychologists, and psychiatrists are estimates of the actual number of mental health professionals in each county. The counts of psychiatric advanced practice nurse are the number of survey respondents in each county. The weights and how each was calculated are described in the Methods section of each chapter. 1

10 Chapter 2: Responses to the 2010 Indiana Mental Health Professionals (Master s-trained) Re-Licensure Survey The results in this chapter reflect the personal and professional characteristics of those master strained mental health professionals licensed in Indiana who responded to the 2010 Indiana Mental Health Professionals Re-Licensure Survey. The master s-trained professionals included in this chapter are social workers, marriage and family therapists, mental health counselors, and other master s-trained mental health professionals. Caution should be taken when making generalizations about all Indiana mental health professionals since those who renewed their license by paper, as well as those who did not respond to the electronic survey, were not included in these results. Consequently, the results shown for the survey respondents may not be representative of all licensed mental health professionals in Indiana. Each table shows the number of valid and missing responses to each survey item and the percentage of valid responses. The text describes the responses to the survey. Methods The data used for this report were extracted from the 2010 Indiana Mental Health Professionals Re-Licensure Survey data files provided by the Indiana State Department of Health and included responses to questions designed to collect information regarding demographic composition, practice characteristics, and special skills or training. A copy of the 2010 Indiana Mental Health Professional Re- Licensure Survey is included in Appendix 1-A. The data provided by the IPLA included date of birth for all licensed mental health professionals who were practicing in Indiana at the time of the survey. The datasets were merged in order to match the respondents approximate age to his or her survey responses. The datasets were merged by matching the license number of each mental health professional using SAS 9.3 and age was calculated using March 1, 2010 as a reference point since surveys were completed from January 30, 2010 through March 31, The merged dataset was then used to filter the records to include only the respondents who met the inclusion criteria. The merged dataset included only those mental health professionals who renewed their license electronically. 2

11 Inclusion and Exclusion Criteria The re-licensure survey dataset was filtered initially to identify all mental health professionals who held an active or probationary license and listed Indiana as their principal practice location. Almost all of the respondents (97.7%) held an active Indiana license (refer to Table 2.1). Table 2.1 Current License Status License Status Number Percent Active 5, Expired Probation Inactive Total 5, The dataset was further refined to include only those mental health professionals who were currently practicing in Indiana. Mental health professionals who were federally employed, retired, temporarily inactive, or practicing outside of Indiana were excluded from the analyses. Government and military employees were excluded because this study is meant to reflect the number of mental health professionals serving the community at large. A total of 4,950 mental health professionals (91.4% of all respondents) were selected for inclusion (refer to Table 2.2). Table 2.2 Current Work Status Work Status Number Percent Excluded from Study Temporarily inactive in mental health positions Mental health professionals active in mental health positions, federally employed Retired Total Excluded from Study Included in Study Mental health professionals active in mental health positions 4, Total Included in Study 4, Total practicing mental health professionals in Indiana 5, Missing 119 *These numbers represent survey respondents only. 3

12 Weighting for County Level Data A key component of identifying potential health profession shortage areas is determining the number of existing professionals in each county. The estimated number of mental health professionals in each county was calculated by summing the number of respondents in each county of principal practice location, then assigning a weight of 89.5 percent to the sum. The weight was determined by calculating the proportion of mental health professionals who renewed their license electronically and responded to at least one question (n = 6,867) to the total number of mental health professional license renewals (n = 7,677) (refer to Table 2.3). Thus, the counts of mental health professionals are estimates of the actual number of mental health professionals in each county and not the number of respondents in each county. The estimated number of mental health professionals per county also does not necessarily reflect the total number of practicing mental health professionals, but the number of mental health professionals available to serve the community at large (excluding government and military employees). Table 2.3 Weighting Calculation for Mental Health Professionals Weighting Calculation Number Percent Renewed electronically and responded to at least one question 6, Total mental health professional renewals in , Survey Response Rate Although only mental health professionals who met the inclusion criteria were included in the analysis portion of this report, the denominator used for determining the survey response rate was based on the total number of mental health professionals who renewed their licenses electronically (refer to Table 2.4). The numerator for those included in the response rate (renewed electronically and responded to at least one question) also included all mental health professionals who renewed electronically, not just those who were included in the analyses. The response rate for those who had the opportunity to take the survey was 95.3 percent. Table 2.4 Survey Response Rate* Mental health professionals Number Percent Renewed electronically & responded to at least one question 6, Did not respond to any questions on the survey Total Electronic Renewals 7, *These numbers represent electronic survey respondents only. 4

13 Demographic Composition Demographic characteristics shown are age, gender, race and ethnicity of survey respondents. The age distribution of respondents is provided in Table 2.5. One-third (32.0%) of the respondents were 44 years of age or younger, while forty percent (40.4%) were at or near retirement age (55 and older). The mean age of respondents was 49.9 years old with a standard deviation of 11.2 years (refer to Table 2.6). Table 2.5 Age Groups* Age Group Number Percent Under ,363 1, and greater Total 4, Missing 26 *These numbers represent survey respondents only. Table 2.6 Age Statistics* Age Statistics Mean Age 49.9 Median Age 51.5 Minimum Age 24.4 Maximum Age 90.4 Standard Deviation 11.2 Total 4,924 Missing 26 *These numbers represent survey respondents only. 5

14 Table 2.7 shows the gender distribution of survey respondents. Over three-fourths (76.6%) of the respondents were female. A cross-tabulation of gender by age is included in Table 2.8. Row percentages indicate the distribution of male and female respondents within each age group. Column percentages are presented in italics and indicate the distribution of age groups within each gender. The trend of females to males is consistent across age groups with a slightly larger gap in those 44 and under (as shown by the row percent, Table 2.8). That difference might indicate that fewer males are entering the field. This trend is consistent with national data for mental health professionals. Table 2.7 Gender* Gender Number Percent Female 3, Male 1, Total 4, Missing 80 *These numbers represent survey respondents only. Table 2.8 Gender by Age Group* Female Male Total Age Groups Number Row Pct Col Pct Number Row Pct Col Pct Number Row Pct Col Pct , , , , and older Total 3, , , Missing 106 *These numbers represent survey respondents only. 6

15 Tables 2.9 and 2.10 display the racial and ethnic distributions of respondents. A majority of the respondents were white (92.4%) and only 2 percent were of Hispanic origin. Table 2.11 includes basic demographic information about the population of Indiana 1. This information is included for comparison with the demographic composition of mental health professionals in Indiana. Table 2.9 Race* Race Number Percent White 4, Black/African American Multi-racial Other Asian/Pacific Islander American Indian Total 4, Missing 314 *These numbers represent survey respondents only Table 2.10 Ethnicity* Hispanic Origin Number Percent No 4, Yes Total 4, Missing 20 *These numbers represent survey respondents only. Table 2.11 Indiana Demographics Indiana Demographic Information Number Percent White 5,467, Black or African American 591, American Indian/Alaska Native 18, Asian 102, Native Hawaiian 2, Hispanic or Latino (of any race) 389, Total Population 6,483, United States Census, 2010 ( 7

16 Practice Characteristics Table 2.12 shows the practice area in which mental health professionals reported they spent the majority of their professional time; it is not based on the type of license the respondent renewed. Almost half (48.3%) of the respondents reported the majority of their time was spent in social work followed by almost forty percent (38.0%) in mental health counseling. Table 2.13 shows the distribution of professional activities that mental health professionals reported required the majority of their time. Respondents indicated they spent most of their time performing activities related to direct patient care (81.2%). Table 2.12 Area in which Most Professional Time Is Spent* Professional Area in which Most Time Is Spent Number Percent Social Work 2, Mental Health Counseling 1, Marriage and Family Therapy Other Profession Total 4, Missing 473 * These numbers represent survey respondents only. Table 2.13 Professional Activities* Area Time Spent Number Percent Direct Client Care or Client Care Related Activities 3, Administration Teaching Other Research Total 4, Missing 50 *These numbers represent survey respondents only. 8

17 The cross tabulation of practice area by age group revealed that over half of the marriage and family therapy professionals were at or near retirement age (55 years of age and older). Social work was the only practice area where the percentage of professionals under 55 years of age was less than forty percent (refer to Table 2.14). Social workers seem to have the youngest workforce, while marriage and family therapists seem to be oldest. Row percentages indicate the distribution of respondents in each age group within each profession, and column percentages represent the distribution of respondents in each profession within an age group. Column percentages are presented in italics. Table 2.14 Profession by Age Group* Professional Area in which Most Row Col Row Col Row Col Time is Spent Number Pct Pct Number Pct Pct Number Pct Pct Social Work Mental Health Counseling Marriage and Family Therapy Other Profession Total Missing * These numbers represent survey respondents only. Table 2.14 Profession by Age Group (Cont d.)* Professional Area and older Total in which Most Row Col Row Col Row Col Time is Spent Number Pct Pct Number Pct Pct Number Pct Pct Social Work , Mental Health Counseling , Marriage and Family Therapy Other Profession Total 1, , Missing 495 * These numbers represent survey respondents only. 9

18 The number of female respondents was three times as high as the number of male respondents; therefore, it is to be expected that the percentage of females would be higher than males in every profession (refer to Table 2.15). Nevertheless, the difference between the percentage of females compared to the percentage of males is less than would be expected in marriage and family therapy (64% female) and slightly higher than expected in social work (81.5%). Row percentages indicate the gender distribution of respondents within each mental health profession, and column percentages represent the percentage of respondents in each profession by gender. Table 2.15 Profession by Gender* Professional Area in Female Male Total which Most Time is Row Col Row Col Row Col Spent Number Pct Pct Number Pct Pct Number Pct Pct Social Work 1, , Mental Health Counseling 1, , Marriage and Family Therapy Other Profession Total 3, , , Missing 531 *These numbers represent survey respondents only 10

19 Table 2.16 shows the distribution of respondents across specialty areas within the mental health profession. Respondents were allowed to select all areas of specialties; therefore, the percent totals will not equal 100 percent. Almost half (48.2%) of the respondents reported their primary specialty area is general mental health. The next three most common specialties were mood disorders (47.5%), anxiety disorder (46.8%) and relationship counseling (39.0%). Respondents averaged just over eight specialties each, indicating that mental health professionals provide a wide range of professional services in their communities. Table 2.15 Specialties of Mental Health Professionals* Specialty Number Percent General Mental Health 2, Mood Disorders 2, Anxiety Disorders 2, Relationships 1, Stress Management 1, Adolescent Counseling 1, Post-traumatic Stress Disorders 1, Grief, Loss or Bereavement 1, Marriage and Family 1, Attention Deficit Disorder (ADHD) 1, Crisis Counseling 1, Personality Disorders 1, Crisis Intervention 1, Addictive Behaviors 1, Family-centered Practice 1, Child Abuse 1, Substance Abuse Disorders 1, Impulse Control Disorders 1, Case Management Community Resources Adult Abuse Aging Issues Schizophrenia and/or Other Psychotic Disorders Anti-social Behavior Sexuality Issues Employee Assistance Program (EAP) Other Specialty Area Child Welfare *These numbers represent survey respondents only. 11

20 Table 2.16 Specialties of Mental Health Professionals (Cont d)* Specialty Number Percent Discharge Planning Learning Disorders Consultation/Liaison Work Eating Disorders Critical Incident Stress Management Dissociative Disorders Medical Treatment Career Counseling Terminal Illness Counseling Mental Retardation Hospice Eldercare Counseling Forensic Social Work Competency Evaluation Disaster Relief Deaf and Hard-of-Hearing Services Genetic Counseling State-operated Facility Assessment and Discharge *These numbers represent survey respondents only. Table 2.17 displays the distribution of patient age groups treated in mental health practices. Respondents were allowed to select all age groups they treated in their practices; therefore, the percent totals will not equal 100 percent. A majority of the respondents indicated they treated adults (79.6%), youth (62.2%), and adolescents (55.3%). Table 2.17 Patient Age Groups Age Groups Number Percent Infants (0-4) Children (5-9) 2, Adolescents (10-14) 2, Youth (15-19) 3, Adults (20-64) 3, Elders (65 and older) 2, I do not provide direct client care services *These numbers represent survey respondents only. 12

21 Table 2.18 displays the average number of hours worked per week performing all mental health activities. The majority of the respondents (67.5%) worked an average of 40 or more hours each week and 17 percent worked less than 30 hours per week. Males accounted for less than 15 percent of the mental health professionals who worked less than 30 hours per week on average (refer to Table 2.19). Furthermore, 76.8 percent of males worked 40 hours or more per week compared with 64.8 percent of female respondents. Row percentages indicate the gender distribution of respondents in each hourly category, and column percentages indicate the percentage of respondents in each hourly category within each gender. Table 2.18 Average Number of Hours Worked Per Week* Average Number of Weekly Hours Number Percent or more 3, Total 4, Missing 244 *These numbers represent survey respondents only. Table 2.19 Average Number of Hours Worked per Week by Gender* Average Female Male Total Weekly Hours Number Row Pct Col Pct Number Row Pct Col Pct Number Row Pct Col Pct or more 2, , Total 3, , , Missing 314 *These numbers represent survey respondents only. 13

22 Less than 10 percent of mental health professionals reported working less than 20 hours per week. Over one-half (52.5%) of the respondents who reported working less than 20 hours per week were 55 years of age or older (refer to Table 2.20). Respondents over 65 years old were less likely to work 40 hours or more per week than respondents 64 and younger. Row percentages indicate the age distribution of respondents in each hourly category. Column percentages represent the distribution of respondents among each hourly category within each age group. Table 2.20 Average Number of Hours Worked per Week by Age Group* Average Under Number of Row Col Row Col Row Col Weekly Hours Number Pct Pct Number Pct Pct Number Pct Pct or more Total , Missing *These numbers represent survey respondents only. Table 2.20 Average Number of Hours Worked per Week by Age Group (Cont d.)* Average and older Total Number of Row Col Row Col Row Col Weekly Hours Number Pct Pct Number Pct Pct Number Pct Pct or more 1, , Total 1, , Missing 268 *These numbers represent survey respondents only 14

23 Special Skills or Training Table 2.21 shows the distribution of additional languages spoken by active Indiana mental health professionals. Almost three percent of respondents indicated they spoke at least one additional language. Spanish was the most common second language at 1.5 percent. Table 2.21 Additional Languages Spoken* Language Number Percent Spanish Sign Language Filipino French Hindi Polish African Languages German Russian Tagalog Arabic Chinese Italian Japanese Pennsylvania Dutch Portuguese Turkish Thai No Additional Languages Spoken 4, *These numbers represent survey respondents only. 15

24 Chapter 3: Responses to the 2010 Clinical Psychologist Re-Licensure Survey The results in this chapter reflect the personal and professional characteristics of those psychologists licensed in Indiana who responded to the 2010 Indiana Clinical Psychologist Re-Licensure Survey. Caution should be taken when making generalizations about all Indiana psychologists since those who renewed their license by paper, as well as those who did not respond to the electronic survey, were not included in these results. Consequently, the results shown for the survey respondents may not be representative of all licensed psychologists in Indiana. Each table shows the number of valid and missing responses to each survey item and the percentage of valid responses. The text describes the responses to the survey. Methods The data used for this report were extracted from the 2010 Indiana Clinical Psychologist Re- Licensure Survey data files provided by the Indiana State Department of Health and included responses to questions designed to collect information regarding demographic composition, practice characteristics, and special skills or training. A copy of the 2010 Indiana Clinical Psychologist Re-Licensure Survey is included in Appendix 1-B. The data provided by the IPLA included date of birth for all licensed clinical psychologists who were practicing in Indiana at the time of the survey. The datasets were merged in order to match the respondent s approximate age to his or her survey responses. The datasets were merged by matching the license number of each clinical psychologist using SAS 9.3 and age was calculated using July 31, 2010 as a reference point since surveys were completed from June 30, 2010 through August 31, The merged dataset was then used to filter the records to include only the respondents that met the inclusion criteria. The dataset included only those psychologists who renewed their license electronically. 16

25 Inclusion and Exclusion Criteria The re-licensure survey dataset was filtered initially to identify all psychologists who held an active or probationary license and listed Indiana as their principal practice location. Almost all of the respondents (99.8%) held an active Indiana license (refer to Table 3.1). Table 3.1 Current License Status License Status Number Percent Active 1, Expired Probation Inactive Total 1, The dataset was further refined by work status to include only those psychologists who were currently practicing in Indiana. Psychologists who were federally employed, state employed, retired, temporarily inactive, or practicing outside of Indiana were excluded from the analyses. Government and military employees were excluded because this study is meant to reflect the number of psychologists serving the community at large. A total of 851 psychologists (86.8% of all respondents) were selected for inclusion (refer to Table 3.2). Table 3.2 Inclusion and Exclusion Criteria* Work Status Number Percent Excluded from Study Psychologists active in mental health position, federally employed Psychologists active in mental health position, state employed Retired Temporarily inactive in mental health position Total Excluded from Study Included in Study Psychologists active in mental health positions Total Included in Study Total Practicing Psychologists in Indiana Missing 0 *These numbers represent survey respondents only. 17

26 Weighting for County Level Data A key component of identifying potential health profession shortage areas is determining the number of existing professionals in each county. The estimated number of clinical psychologists in each county was calculated by summing the number of respondents in each county of principal practice location, then assigning a weight of 88.6 percent to the sum. The weight was determined by calculating the proportion of clinical psychologists who renewed their license electronically and responded to at least one question (n = 1,338) to the total number of clinical psychologist license renewals (n = 1,511) (refer to Table 3.3). Thus, the counts of the psychologists are estimates of the actual number of psychologists in each county and not the number of respondents in each county. The estimated number of psychologists per county also does not necessarily reflect the total number of practicing psychologists, but the number of psychologists available to serve the community at large (excluding government and military employees). Table 3.3 Weighting Calculation for Clinical Psychologists Weighting Calculation Number Percent Renewed electronically and responded to at least one question 1, Total number of psychologist license renewals 1, Survey Response Rate Although only psychologists who met the inclusion criteria were included in the analysis portion of this report, the denominator used for determining the survey response rate was based on the total number of psychologists who renewed their licenses electronically (refer to Table 3.4). The numerator included all psychologists who renewed electronically and responded to at least one question. The response rate for the survey was 99.6 percent. Table 3.4 Response Rate to Survey* Psychologists Number Percent Renewed electronically and responded to at least one question 1, Did not respond to any questions on the survey Total electronic renewals 1, *These numbers represent survey respondents only. 18

27 Demographic Composition Demographic characteristics shown are age, gender, race and ethnicity of survey respondents. The age distribution of respondents is provided in Table 3.5 and basic descriptive statistics of the age distribution are provided in Table 3.6. The mean age of respondents was 51.5 years old with a standard deviation of 11.7 years. Nearly half of respondents (47.7%) were between the ages of 35 and 54. Less than ten percent of respondents were under 35 years old. Table 3.5 Age Groups* Age Number Percent Under and greater Total Missing 6 *These numbers represent electronic survey respondents only. Table 3.6 Age Statistics* Age Statistics Mean Age 51.5 Median Age 51.6 Minimum Age 28.0 Maximum Age 84.1 Standard Deviation 11.7 Total 845 Missing 6 *These numbers represent electronic survey respondents only. 19

28 Table 3.7 shows the gender distribution of survey respondents. Psychologists were split equally among males and females (50.1% and 49.9%, respectively). Age trends indicate that more females have been entering the field in recent years as 80.2 percent of psychologists under the age of 35 were female, while 63.1 percent of psychologists over the age of 54 were male (refer to table 3.8). In Table 3.8, row percentages indicate the gender distribution of respondents within each age group, and column percentages represent the age distribution within each gender. Table 3.7 Gender* Gender Number Percent Female Male Total Missing 3 *These numbers represent electronic survey respondents only. Table 3.8 Gender by Age Group* Female Male Total Age Groups Number Row Pct Col Pct Number Row Pct Col Pct Number Row Pct Col Pct Under and older Total Missing 9 *These numbers represent electronic survey respondents only. 20

29 Tables 3.9 and 3.10 display the racial and ethnic distributions of respondents. A majority of the respondents were of the white race (93.9%) and less than 2 percent were of Hispanic origin. Table 3.11 displays the race of respondents (white or non-white) by age groups. Though the vast majority of psychologists were white, there is a higher percentage of minority respondents under 54 years of age compared to the age groups older than 54 years indicating an increase in minorities entering the field. In Table 3.11, row percentages indicate the racial distribution of respondents within each age group, and column percentages represent the age distribution within each race category. Table 3.9 Race* Race Number Percent White Black/African-American Asian/Pacific Islander Multi-racial Other American Indian/Native Alaskan Total Missing 10 *These numbers represent electronic survey respondents only. Table 3.10 Ethnicity* Hispanic Origin Number Percent No Yes Total Missing 6 *These numbers represent electronic survey respondents only. Table 3.11 Race (White Compared to Non-White) by Age Group* White Non-White Total Age Groups Number Row Pct Col Pct Number Row Pct Col Pct Number Row Pct Col Pct Under and older Total Missing 16 *These numbers represent electronic survey respondents only. 21

30 Practice Characteristics Table 3.12 displays the specialties of respondents. Each respondent was asked to select all specialties which they performed in their work as a psychologist. The most common specialties were anxiety disorders (69.8%), mood disorders (65.5%), and general mental health (52.2%). Respondents averaged over 11 specialties each indicating that psychologists in Indiana serve a wide range of mental healthcare roles. Table 3.12 Specialties of Respondents* Specialties Number Percent Anxiety Disorders Mood Disorders General Mental Health Psychological Assessment/Testing Stress Management ADHD-Attention Deficit Hyperactivity Disorder Post-Trauma Stress Disorder Adolescent Counseling Relationships Grief, Loss or Bereavement Marriage and Family Personality Disorders Child Psychotherapy Learning Disorders Chronic Mental Illness Family Centered Practice Aging Issues Consultation/Liaison Work Impulse Control Disorder Child Abuse Substance Abuse Disorders Addictive Behaviors Adult Abuse Crisis Counseling Sexuality Issues Crisis Intervention Physical Health Issues Anti-social Behavior Schizophrenia/Other Psychotic Disorders *These numbers represent electronic survey respondents only. 22

31 Table 3.12 Specialties of Respondents (Cont d.)* Specialties Number Percent Suicide Counseling Mental Retardation Forensic Psychology Eating Disorders Severe Persistent Mental Illness Neuropsychological Evaluation/Treatment Employee Assistance Programs (EAP) Competency Evaluation Other Specialty Area Evaluation and Placement Medical Treatment Counseling Gerontological Mental Health Dissociative Disorders Career Counseling Elder Care Counseling School Psychology Child Welfare Terminal Illness Counseling Corrections Critical Incident Stress Management Community Resources Extended Care Facility Clients/Issues Disaster Mental Health Discharge Planning AIDS/HIV Psychological First-Aid Elder Abuse Organizational Psychology Public Health Issues Gambling Counseling Hospice State-Operated Facility Assessment & Discharge Planning Disaster Relief Industrial Psychology Deaf & Hard-of-Hearing Services Genetic Counseling Missing 0 *These numbers represent electronic survey respondents only. 23

32 Table 3.13 displays the distribution of patient age groups treated in respondent practices. Respondents were allowed to select all age groups they treated in their practices; therefore, the percent totals will not equal 100 percent. A majority of the respondents indicated they treated adults (87.1%), youth (71.2%), and adolescents (56.6%). Only 6.4 percent of respondents indicated that they did not provide direct patient care services. Table 3.14 shows the distribution of professional activities that psychologists indicated required the majority of their time. Respondents indicated that they spent most of their time performing activities related to direct patient care (79.2%). Table 3.13 Patient Age Groups* Age Groups Number Percent Infants (0-4) Children (5-9) Adolescents (10-14) Youth (15-19) Adults (20-64) Elders (65 and older) I do not provide direct patient care services Missing 7 *These numbers represent electronic survey respondents only. Table 3.14 Professional Activities* Area Time Spent Number Percent Direct patient care/patient care activities Administration Teaching Research Other Total Missing 11 *These numbers represent electronic survey respondents only. 24

33 Table 3.15 displays the average number of hours worked per week performing all professional activities. The majority of the respondents (70.2%) worked an average of 40 or more hours each week and 18.2 percent worked less than 30 hours per week. The number of males and females who worked less than 10 hours and more than 30 hours per week were relatively equal, but the majority of respondents who worked between 10 and 29 hours a week on average were females (68.5%) (refer to table 3.16). In Table 3.16, row percentages indicate the gender distribution of respondents in each hourly category, and column percentages indicate the percentage of respondents in each hourly category within each gender. Table 3.15 Average Number of Hours Worked Per Week* Average Number of Weekly Hours Number Percent or more Total Missing 28 *These numbers represent electronic survey respondents only. Table 3.16 Average Number of Hours Worked Per Week by Gender* Weekly Female Male Total Hours Number Row Pct Col Pct Number Row Pct Col Pct Number Row Pct Col Pct or more Total Missing 30 *These numbers represent electronic survey respondents only. 25

34 Less than 10 percent of psychologists reported working less than 20 hours per week. Of those working less than 20 hours per week on average, over one-half (58.2%) were 55 years of age or older. Of those working greater than 40 hours per week on average, one-half (51.5%) were between the ages of 35 and 54 (refer to Table 3.17). Row percentages indicate the age distribution of respondents in each hourly category. Column percentages represent the distribution of respondents among each hourly category within each age group. Table 3.17 Average Number of Hours Worked per Week by Age Group* Under Weekly Row Col Row Col Row Col Hours Number Pct Pct Number Pct Pct Number Pct Pct or more Total Missing *These numbers represent electronic survey respondents only. Table 3.17 Average Number of Hours Worked per Week by Age Group (Cont d.)* 65 and older Total Weekly Row Col Row Col Hours Number Pct Pct Number Pct Pct or more Total Missing 34 *These numbers represent electronic survey respondents only. 26

35 Special Skills or Training Table 3.18 shows the distribution of additional languages spoken by active Indiana psychologists. Almost five percent of respondents indicated they spoke at least one additional language. Spanish was the most common second language at 1.5 percent. Table 3.18 Additional Languages Spoken* Language Number Percent Spanish French German Hindi Chinese Polish Arabic Filipino Italian Sign Language No additional languages spoken Missing 0 *These numbers represent electronic survey respondents only. 27

36 Chapter 4: Responses of 2011 Indiana Physician Survey, Psychiatrists Only This chapter summarizes the responses made by psychiatrists to the 2011 Indiana Physician Re- Licensure Survey. Psychiatric physicians were identified when a physician selected one of the following major psychiatric specialties: addiction medicine, psychiatry, addiction psychiatry, child psychiatry, forensic psychiatry, geriatric psychiatry, pain medicine psychiatry, psychoanalysis psychiatry, or psychosomatic medicine psychiatry. Caution should be taken when making generalizations about all Indiana psychiatrists since those who renewed their license by paper, as well as those who did not respond to the electronic survey, were not included in these results. Consequently, the results shown for the survey respondents may not be representative of all licensed psychiatrists in Indiana. Each table shows the number of valid and missing responses to each survey item and the percentage of valid responses. The text describes the responses to the survey. Methods The data used to generate this report were extracted from the 2011 Indiana Physician Re- Licensure Survey dataset collected by the ISDH and the physician license dataset maintained by the IPLA. The survey contained questions on respondents principle practice location, residency/training location, average hours worked per week, and demographic information. A copy of the 2011 Indiana Physician Re-Licensure Survey is included in Appendix 1-C. The data provided by the IPLA included date of birth for all licensed physicians who were practicing in Indiana at the time of the survey. The datasets were merged in order to match the respondents approximate age to his or her survey responses. The data sets were merged by matching the license number of each physician using SAS 9.3 and age was calculated using May 31, 2011 as a reference point since surveys were completed from April 30, 2011 through June 30, The merged dataset was then used to filter the records to include only the respondents that met the inclusion criteria. Only physicians whose specialties were among those listed at the beginning of the chapter were included in the analysis. 28

37 Inclusion and Exclusion Criteria The merged dataset was filtered initially to include only psychiatric physicians with an active or probationary license and who reported an Indiana address for their primary practice location. Almost all of the respondents who reported Indiana as their primary practice location held an active Indiana license (refer to Table 4.1). Table 4.1 Current License Status License Status Number Percent Active Expired Probation Inactive Total The dataset was further refined by work status. Only those psychiatrists who were currently practicing in Indiana were included in the analyses. Psychiatrists who were retired, temporarily inactive, practicing outside of Indiana, or working for the government or military were excluded from the analyses. Government and military employees were excluded because this study is meant to reflect the number of psychiatric physicians serving the community at large. A total of 459 psychiatric physicians (98.5%) were selected for inclusion (refer to Table 4.2). Table 4.2 Current Work Status Work Status Number Percent Excluded from Study Retired from active medical practice Inactive in medicine Total Excluded from Study Included in Study Physician actively seeing patients-full Time Physician actively seeing patients-part Time Physician in training (medical resident/fellow) Physician active in medicine, locum tenens ONLY Physician active in medicine, not seeing patients Total Included in Study Total Practicing Psychiatrists in Indiana Missing 0 29

38 Weighting for County Level Data A key component of identifying potential health profession shortage areas is determining the number of existing professionals in each county. The estimated number of psychiatrists in each county was calculated by summing the number of respondents in each county of principal practice location, then assigning a weight of 83.9 percent to the sum. The weight was determined by calculating the proportion of all physicians who renewed their license electronically and responded to at least one question (n = 19,326) to the total number of physician license renewals (n = 23,026) (refer to Table 4.3). The weighting was calculated using data from all physicians since psychiatrists are a subset of this group and there is not a separate dataset available for psychiatrists alone. Thus, the counts of psychiatrists are estimates of the actual number of psychiatrists in each county and not the number of respondents in each county. The estimated number of psychiatrists per county also does not necessarily reflect the total number of practicing psychiatrists, but the number of psychiatrists available to serve the community at large (excluding government and military employees). Table 4.3 Weighting Calculation for Psychiatric Physicians Weighting Calculation Number Percent Renewed electronically and responded to at least one question 19, Total number of physician license renewals 23, Survey Response Rate Although only psychiatrists who met the inclusion criteria were included in the analysis portion of this report, the denominator used for determining the survey response rate was based on the total number of physicians who renewed their licenses electronically (refer to Table 4.4). The numerator for those included in the response rate (renewed electronically and responded to at least one question) also included all physicians who renewed electronically, not just those who were included in the analysis. The response rate for those who had the opportunity to take the survey was 90.3 percent. Table 4.4 Survey Response Rate Survey Response Rate Number Percent Renewed electronically and responded to at least one question 19, Total number of electronic renewals 21,

39 Demographic Composition Table 4.6 shows the age distribution of survey respondents. Almost one-half of respondents (46.6%) were between the ages of 35 and 54. Approximately one-sixth of respondents (17.4%) were over the age of 65. The mean age of respondents was 53.6 years old with a standard deviation of 11.6 years (Table 4.7). Of the psychiatric physicians who responded to the survey questions, approximately twothirds (64.8%) were male and one-third (35.2%) were female (Table 4.5). Table 4.6 Age* Age Number Percent Under to to and older Total Missing 4 *These numbers represent survey respondents only. Table 4.7 Age Statistics* Age Statistics Mean Age 53.6 Median Age 53.7 Minimum Age 27.9 Maximum Age 85.9 Standard Deviation 11.6 Total 455 Missing 4 *These numbers represent survey respondents only. Table 4.5 Gender of Survey Respondents* Gender Number Percent Male Female Total Missing 13 *These numbers represent survey respondents only. 31

40 In Table 4.8, row percentages indicate the gender distribution of respondents within each age group, and column percentages represent the age distribution within each gender. The ratio of males to females differs between age groups (Table 4.8). Psychiatrists under the age of 35 show the smallest gap between males and females (55.2% and 44.8%, respectively). Respondents between 35 and 54 years old were slightly more skewed toward males (57.4% and 42.6%, respectively). The gender gap widened for respondents between 55 and 64 years old (70.5% males and 29.5% female). Respondents over age 65 showed the greatest disparity between males and females (80.5% and 19.5%, respectively). This trend indicates that psychiatry was a field formerly dominated by males, but more females have been entering the field in recent years. Table 4.8 Gender by Age Group* Female Male Total Row Col Row Col Row Col Age Number Pct Pct Number Pct Pct Number Pct Pct Under to to and older Total Missing 17 *These numbers represent survey respondents only. 32

41 Tables 4.9 and 4.10 display the racial and ethnic distribution of respondents. A majority of respondents were white (70.0%) and only 4.0 percent were of Hispanic or Latino ethnicity. Table 4.11 provides age groups for white and non-white respondents. In Table 4.11, row percentages indicate the racial distribution of respondents within each age group, and column percentages represent the age distribution within each racial category. All age groups have roughly 30 percent non-white respondents; however, those under 35 years old have the highest percentage of non-white respondents (34.5%), which may indicate an increase in diversity. Table 4.9 Race* Race Number Percent White Asian Black/African American Multi-racial American Indiana/Native Alaskan Native Hawaiian/Pacific Islander Total Missing 9 *These numbers represent survey respondents only. Table 4.10 Ethnicity* Hispanic Origin Number Percent Not Hispanic or Latino Hispanic or Latino Total Missing 14 *These numbers represent survey respondents only. Table 4.11 Race by Age Group* White Non-White Total Row Col Row Col Row Col Age Number Pct Pct Number Pct Pct Number Pct Pct Under to to and older Total Missing 13 *These numbers represent survey respondents only. 33

42 Education or Training The locations of the respondents residency and fellowship training are shown in Table Respondents were allowed to select more than one location. The majority (68.9%) of the survey respondents completed residency and/or fellowship training in the United States but not in Indiana. Less than four percent of the survey respondents completed residency and/or fellowship training in a country other than the United States. Table 4.12 Residency and/or Fellowship Training Location* Fellowship/Residency Locations Number Percent Other U.S. State Indiana Other Country (not U.S. or Canada) Canada Missing 4 *These numbers represent survey respondents only. Practice Characteristics Over half (57.9%) of the respondents worked 40 or more hours per week and under 25 percent worked less than 30 hours per week (refer to Table 4.13). Table 4.13 Average Number of Hours Worked per Week* Average Number of Weekly Hours in Direct Patient Care Number Percent or more Total Missing 0 *These numbers represent survey respondents only. 34

43 Table 4.14 shows the average number of hours worked per week by respondents by gender. Almost three-quarters (72.7%) of psychiatrists working 40 hours or more per week were male. Furthermore, the percentage of males working 40 hours or more per week (64.4%) is greater than the percentage of females working 40 hours or more per week (44.6%). In Table 4.14, row percentages indicate the gender distribution of respondents in each hourly category, and column percentages indicate the percentage of respondents in each hourly category within each gender. Table 4.15 shows the specialties of respondents. General psychiatry was the most common specialty (65.1%) followed by child psychiatry (16.9%) and geriatric psychiatry (3.0%). Table 4.14 Average Number of Hours Worked per Week by Gender* Average Female Male Total Weekly Hours Number Row Pct Col Pct Number Row Pct Col Pct Number Row Pct Col Pct or more Total Missing 13 *These numbers represent survey respondents only. Table 4.15 Specialties of Indiana Psychiatrists* Specialty Number Percent Psychiatry Psychiatry-Child Psychiatry-Geriatric Addiction Medicine Psychiatry-Addiction Psychiatry-Forensic Psychiatry-Psychosomatic Medicine Psychiatry-Pain Medicine Total Missing 0 *These numbers represent survey respondents only. 35

44 An important component of workforce composition is determining the number of providers that accept Medicaid patients. Three-quarters (75.9%) of respondents indicated that they accepted patients with Medicaid insurance (refer to Table 4.16). Though these respondents may accept individuals with Medicaid insurance, these data do not indicate if each psychiatrist is currently seeing any patients with Medicaid so it is difficult to measure the actual amount of service respondents provide to underprivileged members of their community. Table 4.16 Psychiatrists who Accept Medicaid* Accept Medicaid Patients Number Percent No Yes Total Missing 3 *These numbers represent survey respondents only. The numbers of respondents who reported working with either advanced practice nurses or physician assistants are listed in Tables 4.17 and Nearly one-third (30.2%) of respondents worked with an advanced practice nurse, but less than two percent (1.8%) worked with a physician assistant. Table 4.17 Advanced Practice Nurses* Works with Advanced Practice Nurse Number Percent No Yes Total Missing 5 *These numbers represent survey respondents only. Table 4.18 Physician Assistants* Works with Physician Assistant Number Percent No Yes Total Missing 3 *These numbers represent survey respondents only. 36

45 Chapter 5: Responses to the 2011 Indiana Psychiatric Advanced Practice Nurse Electronic Survey This chapter summarizes the responses to the items included on the 2011 psychiatric/mental health nurse survey. This survey was introduced for the first time in The tables below display the number of valid and missing responses and the percentage of valid responses. The text describes the tables. Methods This survey was not conducted as part of the re-licensing process. Advanced practice nurses were invited to participate in the survey by using a snowball strategy to disseminate the survey to clinical nurse specialists and nurse practitioners that practice in the field of mental health. The survey includes questions about respondents practice setting, principle practice location, specialties, expected time until retirement, education, and demographic information. A copy of the 2011 Indiana Psychiatric Advanced Practice Nurse Electronic Survey is included in Appendix 1-D. It is difficult to estimate the total number of these professionals in Indiana since they are not licensed separately from other nurses who do not specialize in psychiatric treatment. The data was compiled using Microsoft Excel 2007 and the data was analyzed using IBM SPSS Statistics 19. The dataset was then used to filter the records to include only the respondents that met the inclusion criteria. Inclusion and Exclusion Criteria Because psychiatric advanced practice nurses (clinical nurse specialists and nurse practitioners specializing in psychiatric/mental health) are not licensed separately from other nurses and survey respondents were not linked to IPLA datasets containing licensing information, it is not possible to determine respondents current license status. However, the dataset was refined by current work status. Only those psychiatric advanced practice nurses who were currently working in the mental health field in Indiana were included in the study. Psychiatric advanced practice nurses who were retired, temporarily inactive, practicing outside of Indiana, or working for the government or military were excluded from the analyses. Government and military employees were excluded because this study is meant to reflect the number of psychiatric advanced practice nurses serving the community at large. A total of 61 psychiatric advanced practice nurses (87.1%) were selected for inclusion (refer to Table 5.1). 37

46 Table 5.1 Current Work Status* Work Status Number Percent Excluded from Study Retired or permanently inactive as a nurse Actively working, but not as a nurse or in health care Unemployed and seeking work as a nurse in Indiana Actively working in health care, but not in psychiatric/mental health nursing Total Excluded from Study Included in Study Actively working as a psychiatric/mental health nurse Total Included in Study Total survey respondents Missing 0 * These numbers represent survey respondents only. Weighting for County Level Data Because separate licensure data is not kept for psychiatric advanced practice nurses it is difficult to estimate the total number of psychiatric advanced practice nurses licensed in Indiana. An estimate was made using data from the 2009 Nurse Re-Licensure Survey. Clinical nurse specialists and nurse practitioners were extracted from the 2009 data set and filtered by practice setting. Nurses practicing in community mental health organizations/facilities (n = 400), state mental health agencies (n = 122), and substance abuse centers/clinics (n = 51) were assumed to be psychiatric advanced practice nurses, and the totals in each setting were summed to estimate the total number of professionals in this field. The weight was calculated by using total respondents from the 2011 Psychiatric Advanced Practice Nurse Electronic Survey (n = 52) as the numerator and the estimated total number of psychiatric advanced practice nurses (n = 573) as the denominator for a weight of 9.1 percent. However, because the weight was so small it was decided that it would inflate the numbers of respondents in each county too much to yield an accurate estimate of the true number of psychiatric advanced practice nurses in each county. Therefore, the weight was not used to adjust the total number of respondents. The county level data for psychiatric advanced practice nurses displayed in the maps in Chapter 6 reflect the number of respondents in each county and not an estimation of the workforce. 38

47 Survey Response Rate Since the survey was disseminated using a snowball technique it is not possible to estimate the survey response rate. Demographic Composition The gender distribution for clinical nurse specialists or nurse practitioners specializing in psychiatric/mental health is shown in Table 5.2. A majority of the respondents (92.2%) were female. Tables 5.3 and 5.4 display the races and ethnicity of survey respondents. The majority of respondents were white (96.2%) and non-hispanic (98.0%). Table 5.2 Gender of Survey Respondents* Gender Number Percent Male Female Total Missing 1 * These numbers represent survey respondents only. Table 5.3 Race of Survey Respondents* Race Number Percent White Black/African American Multi-racial Other Asian/Pacific Islander American Indian or Native Alaskan Total Missing 0 * These numbers represent survey respondents only. Table 5.4 Ethnicity of Survey Respondents* Ethnicity Number Percent Hispanic/Latino Not Hispanic/Latino Total Missing 3 * These numbers represent survey respondents only. 39

48 Education or Training Table 5.5 shows the highest degree in nursing reported by the psychiatric/mental health nurse survey respondents. Seventy-five percent of the respondents indicated they had a master s degree. Around 11 percent of the respondents reported they had a doctorate of some type. Table 5.5 Highest Degree in Nursing of Survey Respondents* Degree Number Percent Master's Doctor of Nursing Practice (DNP) Doctorate Other Other Total Missing 0 * These numbers represent survey respondents only. Professional Characteristics Table 5.6 shows the respondents type of nursing position. Two-thirds (66.7%) of the respondents providing patient care were advanced practice registered nurses (psych clinical nurse specialist) with prescriptive authority and approximately one-fifth (22.9%) were advanced practice registered nurses without prescriptive authority. Table 5.6 Survey Respondents Type of Position as a Nurse* Position Number Percent Advanced Practice Registered Nurse (psych clinical nurse specialist) with prescriptive authority Advanced Practice Registered Nurse (psych clinical nurse specialist) without prescriptive authority Advanced Practice Registered Nurse (psych nurse practitioner) with prescriptive authority Total Missing 4 * These numbers represent survey respondents only. 40

49 Table 5.7 displays the principal work setting of the psychiatric/mental health nurse survey respondents. The two most common work settings were public or community health (30.8%) and hospital (26.9%) settings. Table 5.8 represents all activities in which each respondent was involved in the course of their work as a clinical nurse specialist or nurse practitioner specializing in psychiatric/mental health. Since respondents were able to select each activity that applied to them the percentages do not add to 100 percent. Percentages represent the proportion of respondents who participate in each activity. The most common activities among respondents were clinical supervision/education (80.8%) and psychopharmacological interventions (78.8%). However, respondents seem to provide a diversity of healthcare activities since each activity is carried out by over 50 percent of respondents. Table 5.7 Principal Work Setting of Survey Respondents* Setting Number Percent Public or Community Health Setting Hospital (on-site, including Federal) Nursing Education Program Group or Solo Practice Other State Mental Health Agency Total Missing * These numbers represent survey respondents only. Table 5.8 All Work Activities Performed by Survey Respondents* Activities Number Percent Clinical Supervision/Education Psychopharmacological Interventions Psychotherapy - individual, group Consultation and Liaison Case Management Program Development and Management * These numbers represent survey respondents only. 41

50 Table 5.9 represents survey respondents primary activity that they perform while working as a psychiatric/mental health nurse. Over one-half of respondents (55.8%) said that their primary work activity was psychopharmacological interventions. Table 5.10 shows the average number of hours worked per week in all nursing activities by the psychiatric advanced practice nurse survey respondents. Almost one-half (47.1%) of the respondents worked an average of 41 or more hours per week. Table 5.9 Primary Work Activity Performed by Survey Respondents* Primary Activity Number Percent Psychopharmacological Interventions Clinical Supervision/Education Psychotherapy - individual, group Consultation and Liaison Program Development and Management Case Management * These numbers represent survey respondents only. Table 5.10 Average Number of Hours Worked per Week in All Nursing Activities by Survey Respondents* Hours Number Percent or more Total Missing 1 * These numbers represent survey respondents only. 42

51 Table 5.11 displays whether the psychiatric/mental health nurse survey respondents hold more than one paid position. One-quarter (25.0%) of respondents indicated that they worked more than one job, and 17.3 percent reported holding a second job in another psychiatric/mental health setting. Table 5.11 Number of Respondents who Work Multiple Jobs* Multiple Jobs? Number Percent No Yes, in another psychiatric/mental health setting Yes, in a non-psychiatric/mental health setting Total Missing 0 * These numbers represent survey respondents only. Table 5.12 shows respondents anticipated time until retirement. Over one-half (55.8%) of respondents indicated that they were still at least 10 years away from retirement. Approximately 41 percent (40.4%) said they planned to retire in the next four to nine years. Table 5.12 Anticipated Time of Retirement by Survey Respondents* Years Number Percent or more Total Missing 0 * These numbers represent survey respondents only. 43

52 Chapter 6: Location of Mental Health Professionals by County in Indiana The following maps display the estimated number of mental health professionals by county and the ratio of mental health professionals per 100,000 population. The estimates were determined based on the respondents principal practice location. The total number of respondents from each county was weighted to estimate the actual number of mental health professionals in each county who provided care to the community-at-large. Each group of health professionals were weighted separately. The calculation and rationale for each weight is presented in the Methods section of each chapter in this report. For convenience, the weights used for each type of mental health professional are summarized in Table 6.1. All Master s trained mental health professionals (social workers, marriage and family therapists, mental health counselors, and other professionals) used the same weight. The number of psychiatric advanced practice nurses was NOT weighted. Thus, the counts of these mental health professionals and ratio are estimates of the actual number of mental health professionals in each county and not the number of respondents in each county (except psychiatric advanced practice nurses). The numbers presented in the tables reflect the weighted frequencies of each county. The hash marks indicate rural counties defined by the United States Department of Agriculture as non-metropolitan counties. Table 6.1 Weights Used for County Level Data Profession Weight Master's Trained Mental Health Professionals 89.5 Clinical Psychologists 88.6 Psychiatric Physicians 83.9 Advanced Practice Psychiatric Nurses n/a 44

53 Masters-trained Mental Health Professionals Distribution Map 6.1 shows that the total number of masters- trained mental health professionals in Indiana counties is distributed roughly by population. As expected, the counties with the largest populations have the greatest number of mental health professionals. These counties include Allen, Bartholomew, Clark, Delaware, Elkhart, Hamilton, Howard, Johnson, Lake, Madison, Marion, Monroe, Porter, St. Joseph, Tippecanoe, Vanderburgh, and Vigo. Three counties had no mental health professionals practicing in them: Benton, Ohio, and Union counties. The hash marks indicate rural counties defined by the United States Department of Agriculture as non-metropolitan counties. Map 6.1 Estimated Number of Mental Health Professionals by County,

54 Map 6.2 shows that the number of mental health social workers in Indiana counties is distributed roughly by population. As expected, the counties with the largest populations have the greatest number of mental health social workers. These counties include Allen, Lake, Marion, St. Joseph and Vanderburgh. Seven counties had no social workers practicing in them. The hash marks indicate rural counties defined by the United States Department of Agriculture as non-metropolitan counties. Map 6.2 Estimated Number of Mental Health Social Workers by County,

55 Map 6.3 shows that the number of marriage and family therapists in Indiana counties is distributed roughly by population. As expected, the counties with the largest populations have the greatest number of marriage and family therapists. These counties include Allen, Elkhart, Hamilton, Lake, Marion, Monroe, St. Joseph, Tippecanoe, and Vanderburgh. Thirty-eight counties had no marriage and family therapists practicing within them. The hash marks indicate rural counties defined by the United States Department of Agriculture as non-metropolitan counties. Map 6.3 Number of Marriage and Family Therapists by County,

56 Map 6.4 shows that the number of mental health counselors in Indiana counties is distributed roughly by population. As expected, the counties with the largest populations have the greatest number of mental health counselors. These counties include Allen, Clark, Delaware, Elkhart, Hamilton, Hendricks, Howard, Johnson, Lake, Madison, Marion, Monroe, Porter, St. Joseph, Tippecanoe, and Vanderburgh. Seven counties had no mental health counselors practicing in them. The hash marks indicate rural counties defined by the United States Department of Agriculture as non-metropolitan counties. Map 6.4 Number of Mental Health Counselors by County,

57 Map 6.5 shows that the number of other mental health professionals in Indiana counties is distributed roughly by population. As expected, the counties with the largest populations have the greatest number of other mental health professionals. These counties include Allen, Bartholomew, Elkhart, Hamilton, Lake, LaPorte, Marion, Monroe, St. Joseph, Tippecanoe, and Vanderburgh. Forty-one counties had no other mental health professionals practicing in them. The hash marks indicate rural counties defined by the United States Department of Agriculture as non-metropolitan counties. Map 6.5 Number of Other Mental Health Professionals by County,

58 Psychologists Distribution Map 6.6 displays the number of psychologists by Indiana counties for As expected, the counties with the largest populations have the highest number of psychologists including Allen, Bartholomew, Delaware, Hamilton, Johnson, Lake, LaPorte, Madison, Marion, Monroe, Porter, St. Joseph, Tippecanoe, Vanderburgh, and Vigo. Thirty counties had no psychologists practicing in them. The hash marks indicate rural counties defined by the United States Department of Agriculture as nonmetropolitan counties. Map 6.6 Number of Clinical Psychologists by County,

59 Psychiatrists Distribution Map 6.7 shows that the number of psychiatrists in Indiana counties is distributed roughly by population. As expected, the counties with the largest populations have the greatest number of psychiatric physicians. These counties include Allen, Clark, Elkhart, Hamilton, Lake, Marion, Monroe, St. Joseph, and Vanderburgh. Fifty counties had no psychiatrists practicing within them. The hash marks indicate rural counties defined by the United States Department of Agriculture as non-metropolitan counties. Map 6.7 Number of Psychiatrists by County,

60 Psychiatric Advanced Practice Nurses Distribution Map 6.8 shows the distribution of psychiatric advanced practice nurses practicing in the state. The counties with the highest population were the only counties that had any psychiatric advanced practice nurses practicing within them. Marion, Monroe, Vanderburgh, and Vigo counties had the highest numbers of psychiatric advanced practice nurses. Eighty counties didn t have any practicing psychiatric advanced practice nurse respondents. The hash marks indicate rural counties defined by the United States Department of Agriculture as non-metropolitan counties. Map 6.8 Number of Psychiatric Advanced Practice Nurses by County,

61 Table 6.2 Estimated Number of Mental Health Professionals by County, 2010 County Population All MH Professionals Social Workers Marriage and Family Therapists Mental Health Counselors Other Professions Adams 34, Allen 355, Bartholomew 76, Benton 8, Blackford 12, Boone 56, Brown 15, Carroll 20, Cass 38, Clark 110, Clay 26, Clinton 33, Crawford 10, Daviess 31, Dearborn 25, Decatur 42, DeKalb 50, Delaware 117, Dubois 41, Elkhart 197, Fayette 24, Floyd 74, Fountain 17, Franklin 23, Fulton 20, Gibson 33, Grant 70, Greene 33, Hamilton 274, Hancock 70, Harrison 39, Hendricks 145, Henry 49, Howard 82, Huntington 37, Jackson 42, Jasper 33, Jay 21,

62 Table 6.2 Estimated Number of Mental Health Professionals by County, 2010 (Cont d.) Marriage and Family Therapists Mental Health Counselors County Population All MH Professionals Social Workers Jefferson 32, Jennings 28, Johnson 139, Knox 38, Kosciusko 77, LaGrange 37, Lake 496, LaPorte 111, Lawrence 46, Madison 131, Marion 903,393 1, Marshall 47, Martin 10, Miami 36, Monroe 137, Montgomery 38, Morgan 68, Newton 14, Noble 47, Ohio 6, Orange 19, Owen 21, Parke 17, Perry 19, Pike 12, Porter 164, Posey 25, Pulaski 13, Putnam 37, Randolph 26, Ripley 28, Rush 17, Scott 24, Shelby 44, Spencer 20, St. Joseph 266, Starke 23, Steuben 34, Other Professions 54

63 Table 6.2 Estimated Number of Mental health Professionals by County, 2010 (Cont d.) Marriage and Family Therapists Mental Health Counselors County Population All MH Professionals Social Workers Sullivan 21, Switzerland 10, Tippecanoe 172, Tipton 15, Union 7, Vanderburgh 179, Vermillion 16, Vigo 107, Wabash 32, Warren 8, Warrick 59, Washington 28, Wayne 68, Wells 27, White 24, Whitley 33, Table 6.3 Estimated Number of Clinical Psychologists by County, 2010 County Population Psychologists Adams 34,387 1 Allen 355, Bartholomew 76, Benton 8,854 2 Blackford 12,766 0 Boone 56,640 2 Brown 15,242 2 Carroll 20,155 0 Cass 38,966 2 Clark 110,232 8 Clay 26,890 6 Clinton 33,224 0 Crawford 10,713 0 Daviess 31,648 0 Dearborn 25,740 5 Decatur 42,223 0 DeKalb 50,047 0 Delaware 117, Dubois 41,889 6 Other Professions 55

64 Table 6.3 Estimated Number of Clinical Psychologists by County, 2010 (Cont d.) County Population Psychologists Elkhart 197, Fayette 24,277 0 Floyd 74,578 6 Fountain 17,240 1 Franklin 23,087 0 Fulton 20,836 1 Gibson 33,503 0 Grant 70,061 7 Greene 33,165 1 Hamilton 274, Hancock 70,002 7 Harrison 39,364 1 Hendricks 145, Henry 49,462 3 Howard 82, Huntington 37,124 3 Jackson 42,376 9 Jasper 33,478 2 Jay 21,253 0 Jefferson 32,428 7 Jennings 28,525 2 Johnson 139, Knox 38,440 6 Kosciusko 77,358 6 LaGrange 37,128 0 Lake 496, LaPorte 111, Lawrence 46,134 2 Madison 131, Marion 903, Marshall 47,051 1 Martin 10,334 0 Miami 36,903 1 Monroe 137, Montgomery 38,124 3 Morgan 68,894 1 Newton 14,244 0 Noble 47,536 0 Ohio 6,128 0 Orange 19,840 1 Owen 21,

65 Table 6.3 Estimated Number of Clinical Psychologists by County, 2010 (Cont d.) County Population Psychologists Parke 17,339 1 Perry 19,338 0 Pike 12,845 0 Porter 164, Posey 25,910 0 Pulaski 13,402 0 Putnam 37,963 3 Randolph 26,171 0 Ripley 28,818 1 Rush 17,392 0 Scott 24,181 0 Shelby 44,436 3 Spencer 20,952 3 St. Joseph 266, Starke 23,363 1 Steuben 34,185 0 Sullivan 21,475 7 Switzerland 10,613 0 Tippecanoe 172, Tipton 15,936 0 Union 7,516 0 Vanderburgh 179, Vermillion 16,212 1 Vigo 107, Wabash 32,888 1 Warren 8,508 0 Warrick 59,689 2 Washington 28,262 0 Wayne 68,917 7 Wells 27,636 2 White 24,643 1 Whitley 33,

66 Table 6.4 Estimated Number of Psychiatrists by County, 2011 County Population Psychiatrists Adams 34,387 0 Allen 355, Bartholomew 76,794 7 Benton 8,854 0 Blackford 12,766 0 Boone 56,640 6 Brown 15,242 0 Carroll 20,155 0 Cass 38, Clark 110, Clay 26,890 0 Clinton 33,224 1 Crawford 10,713 0 Daviess 31,648 2 Dearborn 25,740 6 Decatur 42,223 0 DeKalb 50,047 0 Delaware 117, Dubois 41,889 2 Elkhart 197, Fayette 24,277 1 Floyd 74,578 5 Fountain 17,240 0 Franklin 23,087 0 Fulton 20,836 0 Gibson 33,503 0 Grant 70, Greene 33,165 0 Hamilton 274, Hancock 70,002 4 Harrison 39,364 0 Hendricks 145, Henry 49,462 0 Howard 82, Huntington 37,124 0 Jackson 42,376 1 Jasper 33,478 0 Jay 21,253 0 Jefferson 32,428 6 Jennings 28,525 0 Johnson 139,

67 Table 6.4 Estimated Number of Psychiatrists by County, 2011 (Cont d.) County Population Psychiatrists Knox 38, Kosciusko 77,358 1 LaGrange 37,128 0 Lake 496, LaPorte 111,467 6 Lawrence 46,134 1 Madison 131,636 8 Marion 903, Marshall 47,051 4 Martin 10,334 0 Miami 36,903 0 Monroe 137, Montgomery 38,124 0 Morgan 68,894 0 Newton 14,244 0 Noble 47,536 0 Ohio 6,128 0 Orange 19,840 0 Owen 21,575 0 Parke 17,339 1 Perry 19,338 0 Pike 12,845 0 Porter 164,343 7 Posey 25,910 0 Pulaski 13,402 0 Putnam 37,963 2 Randolph 26,171 0 Ripley 28,818 0 Rush 17,392 0 Scott 24,181 0 Shelby 44,436 0 Spencer 20,952 0 St. Joseph 266, Starke 23,363 0 Steuben 34,185 1 Sullivan 21,475 1 Switzerland 10,613 0 Tippecanoe 172, Tipton 15,936 0 Union 7,

68 Table 6.4 Estimated Number of Psychiatrists by County, 2011 (Cont d.) County Population Psychiatrists Vanderburgh 179, Vermillion 16,212 0 Vigo 107, Wabash 32,888 0 Warren 8,508 0 Warrick 59,689 2 Washington 28,262 0 Wayne 68, Wells 27,636 0 White 24,643 1 Whitley 33,292 0 Table 6.5 Number of Psychiatric Advanced Practice Nurses by County, 2011 County Population Psychiatric Nurses Adams 34,387 0 Allen 355,329 2 Bartholomew 76,794 0 Benton 8,854 0 Blackford 12,766 0 Boone 56,640 1 Brown 15,242 0 Carroll 20,155 0 Cass 38,966 2 Clark 110,232 1 Clay 26,890 0 Clinton 33,224 0 Crawford 10,713 0 Daviess 31,648 0 Dearborn 25,740 0 Decatur 42,223 0 DeKalb 50,047 0 Delaware 117,671 0 Dubois 41,889 0 Elkhart 197,559 0 Fayette 24,277 0 Floyd 74,578 0 Fountain 17,240 0 Franklin 23,087 0 Fulton 20,836 0 Gibson 33,503 0 Grant 70,

69 Table 6.5 Number of Psychiatric Advanced Practice Nurses by County, 2011 (Cont d.) County Population Psychiatric Nurses Greene 33,165 0 Hamilton 274,569 1 Hancock 70,002 0 Harrison 39,364 0 Hendricks 145,448 0 Henry 49,462 0 Howard 82,752 1 Huntington 37,124 0 Jackson 42,376 0 Jasper 33,478 0 Jay 21,253 0 Jefferson 32,428 0 Jennings 28,525 0 Johnson 139,654 0 Knox 38,440 0 Kosciusko 77,358 0 LaGrange 37,128 0 Lake 496,005 0 LaPorte 111,467 0 Lawrence 46,134 0 Madison 131,636 0 Marion 903, Marshall 47,051 0 Martin 10,334 0 Miami 36,903 0 Monroe 137,974 4 Montgomery 38,124 0 Morgan 68,894 0 Newton 14,244 0 Noble 47,536 0 Ohio 6,128 0 Orange 19,840 0 Owen 21,575 0 Parke 17,339 0 Perry 19,338 0 Pike 12,845 0 Porter 164,343 0 Posey 25,910 0 Pulaski 13,402 0 Putnam 37,963 0 Randolph 26,

70 Table 6.5 Number of Psychiatric Advanced Practice Nurses by County, 2011 (Cont d.) County Population Psychiatric Nurses Ripley 28,818 0 Rush 17,392 0 Scott 24,181 0 Shelby 44,436 0 Spencer 20,952 0 St. Joseph 266,931 0 Starke 23,363 0 Steuben 34,185 0 Sullivan 21,475 0 Switzerland 10,613 0 Tippecanoe 172,780 2 Tipton 15,936 0 Union 7,516 0 Vanderburgh 179,703 3 Vermillion 16,212 0 Vigo 107,848 2 Wabash 32,888 0 Warren 8,508 0 Warrick 59,689 0 Washington 28,262 0 Wayne 68,917 2 Wells 27,636 0 White 24,643 0 Whitley 33,

71 Masters Trained Mental Health Professionals Ratios Map 6.9 shows the estimated number of mental health professionals per 100,000 population by county in Indiana. The counties with the highest ratios were generally the counties with highest population. Several less populous counties were also among the counties with the highest ratio of mental health professionals to population, but these counties bordered highly populated counties. The counties with the highest ratios included Allen, Bartholomew, Clark, Dearborn, Delaware, Floyd, Howard, Jefferson, Knox, Madison, Marion, Monroe, Perry, St. Joseph, Tippecanoe, Vanderburgh, Wabash, and Wayne. The hash marks indicate rural counties defined by the United States Department of Agriculture as non-metropolitan counties. Map 6.9 Estimated Number of Mental Health Professionals per 100,000 Population by County,

72 Map 6.10 shows the estimated number of mental health social workers per 100,000 population by county in Indiana. Counties with the highest ratios included the most populous counties, but also counties with low population that bordered highly populated counties. The counties with the highest ratios included Allen, Bartholomew, Dearborn, Dubois, Floyd, Howard, Jefferson, Knox, Marion, Monroe, Perry, St. Joseph, Tippecanoe, Vanderburgh, Vigo, Wabash, and Wayne. The hash marks indicate rural counties defined by the United States Department of Agriculture as non-metropolitan counties. Map 6.10 Estimated Number of Mental Health Social Workers per 100,000 Population by County,

73 Map 6.11 shows the estimated number of marriage and family therapists per 100,000 population by county in Indiana. Ratios were the highest in the most populous counties as well as less populated counties that bordered highly populated counties. Counties with the highest ratios included Allen, Bartholomew, Dearborn, Fayette, Fountain, Franklin, Grant, Hamilton, Jefferson, Marion, Marshall, Tippecanoe, and Vanderburgh. The hash marks indicate rural counties defined by the United States Department of Agriculture as non-metropolitan counties. Map 6.11 Estimated Number of Marriage and Family Therapists per 100,000 Population by County,

74 Map 6.12 shows the estimated number of mental health counselors per 100,000 population by county in Indiana. Ratios were the highest in the most populous counties as well as counties with low population that bordered highly populous counties. Counties with the highest ratios included Allen, Dearborn, Delaware, Fulton, Howard, Knox, Madison, Marion, Monroe, Owen, Parke, Perry, St. Joseph, Vanderburgh, Vermillion, Wabash, and Wayne. The hash marks indicate rural counties defined by the United States Department of Agriculture as non-metropolitan counties. Map 6.12 Estimated Number of Mental Health Counselors per 100,000 Population by County,

75 Map 6.13 shows the estimated number of other mental health professionals per 100,000 population by county in Indiana. Although it seems counter-intuitive, the map illustrates that some of the most populous counties like Allen, Lake, and St. Joseph have fewer mental health professionals per 100,000 residents than some of the counties with smaller populations. Ratios of other mental health professionals were highest in the following counties: Bartholomew, Brown, Crawford, Dubois, Gibson, Greene, Marion, Monroe, Pulaski, Starke, and Steuben. The hash marks indicate rural counties defined by the United States Department of Agriculture as non-metropolitan counties. Map 6.13 Estimated Number of Other Mental Health Professionals per 100,000 Population by County,

76 Psychologists Ratio Map 6.14 represents the number of clinical psychologists per 100,000 people in each Indiana county. Ratios were highest in the most populous counties as well as a few less populated counties that bordered the highly populous counties. Counties with the highest ratios included Allen, Bartholomew, Benton, Clay, Delaware, Hamilton, Jackson, Jefferson, Marion, Monroe, Porter, St. Joseph, Sullivan, Tippecanoe, and Vigo. The hash marks indicate rural counties defined by the United States Department of Agriculture as non-metropolitan counties. Map 6.14 Estimated Number of Psychologists per 100,000 Population by County,

77 Psychiatrists Ratio Map 6.15 shows the estimated number of psychiatric physicians per 100,000 population by county in Indiana. Unexpectedly, Cass county had the highest ratio (43 per 100,000 population). The most populous counties in the state (Marion and Lake) were among the counties with the highest ratios, but in general the counties with the highest ratios were less populated counties. Counties with the highest ratios included Cass, Clark, Dearborn, Howard, Jefferson, Knox, Lake, LaPorte, Marion, Monroe, Vanderburgh, and Wayne. The hash marks indicate rural counties defined by the United States Department of Agriculture as non-metropolitan counties. Map 6.15 Estimated Number of Psychiatric Physicians per 100,000 Population by County,

78 Psychiatric Advanced Practice Nurses Ratio Map 6.16 shows the number of psychiatric advanced practice nurses per 100,000 population by county in Indiana. Cass county had the highest ratio (5 per 100,000 population) followed by Monroe (3 per 100,000 population). Cass is a relatively lowly populated county, so its high ratio is more of a reflection of the low population rather than an unusually high number of psychiatric advanced practice nurses. The hash marks indicate rural counties defined by the United States Department of Agriculture as non-metropolitan counties. Map 6.16 Number of Psychiatric Advanced Practice Nurses per 100,000 Population by County,